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RELEVANT MEASURES FOR MI PEER GROUP 5 CAHs
January 2025
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MBQIP
https://www.ruralcenter.org/resources/data-reporting-and-use
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 Global Measures
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MeasureNarrativeMBQIPHQIC MeasuresBCBSMMICAH RecommendedReported to Submission MethodDeadlinesStatus
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Hospital Commitment to Health Equity MeasuresStructural Measure to Assess Hospital Commitemnt to Health Equity Across 5 Domains
1. Equity is a Strategic Priority
2. Data Collection
3. Data Analysis
4. Quality Improvement
5. Leadership Engagement		xxFMTHQR Secure Portal Annual Submission
May 15, 2025
CY 2024 data		New Measure
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CAH Quality Infrastructure Implementation Structural measure to Assess Hospital quality infrastrucutre based on 9 core elementsxxFMTFMT Qualtrics Platform via link2025 Submission TBD
New Measure
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Patient Safety Measures
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HCP/IMM3Influenza Vaccine Coverage healthcare workersxxNational Healthcare Safety NetworkEnter your data into NHSNAnnual Submission
May 15, 2025
Q4 2024 - Q1 2025 data
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Antimicrobial StewardshipQuestions as Answered to inform whether the facility successfully implemented core elements.
Leadership
Accountability
Drug Expertise
Action
Tracking
Reporting
Education 		xxNational Healthcare Safety NetworkEnter your data into NHSNAnnual Submission
March 1, 2025
CY 2024 data
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Safe Use of Opioids (eCQM)Safe Use of Opioids current measure of the Medicare PI Program.
*Three self-selected meausres of the 13 available for each quarter.
*One required measure- Safe Use of Opioid Measure		xxCMS QRDA Category 1 fileAnnual Submission
March 14,2025
CY 2024 data		New Measure
*this is still a reportable eCQM
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Patient Experience
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HCAHPS
xxHQR HCAHPS Survey Vendor uploads your data to QNet and BCBSM. For hospitals with very low inpatient volume, BCBSM allows them to submit data on only 4 questions. Quartely Submission
Q3 24- Jan 2, 2025
Q4 24 - April 2, 2025
Q1 25, July 2, 2025
Q2 25, Oct 1, 2025
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Care Coordination
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Hybrid All-Cause ReadmissionsHosptial level, all cause, risk standardized readmission measure that focuses on unplanned readmission 30 days of discharge from an acute hospitalizationxxHQRPatient level file in QRDA 1 formatAnnual Submission
October 1, 2025
Q3 2024 - Q2 2025data		New Measure
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SDOH Screening Screening for Social Drivers of Health Measure- Report on:
1) the number of admitted patients who are 18 or older who are screened for each of the 5 HRSN (Food Security, Housing Instability, Transportation Problems, Utility Difficulties, Interpersonal Safety)
and
2) The total number of patients who are admitted that are 18 on the date of admission.		xxHQRChart Abstraction Numerator and Denominator SubmissionAnnual Submission
May 15, 2025
CY 2024 data
New Measure
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SDOH Screening Positive Positive Screen for Social Drivers of Health
Repot on:
% of admitted patients who are 18 or older on the date of admission who screened positive for one or more of the 5 HRSN during the hospital stay. 		xxHQRChart Abstraction Numerator and Denominator Submission via Web based data formAnnual Submission
May 15, 2025
CY 2024 data
New Measure
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Emergency Department
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Emergency Department Transfer Communication Percent of Patients who are transferred from an ED to another healthcare facility whose medical record documentation indicated that ALL 8 data elements were documented and communicated to the receiving hospital in a timely manner.xxMCRH Enter your data into the ED Transfer Communication Data Collection Tool and submit to Crystal Barter Quarterly Submission
1Q 25- to Crystal by April 30th
2Q 25- to Crystal by July 31st
3Q 25 - to Crystal by October 31st
4Q 25 - to Crystal by January 31st
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OP-18 Time from Arrival to DepartureMedican time from Emergency Department arrival to the time of departure from the emergency room for patients discharged from the ED.xxHQRCore Measures Vendor uploads your data to QNet or enter your data directly in the QNet CART Quarterly Submission
Q3 24 - Feb 3, 2025
Q4 24 - May 1, 2025
Q1 25, Aug 1, 2025
Q2 25 - Nov 1, 2025
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OP-22 Left without Being Seen Percent of Patients who leave the Emergency Department without being evaluated by a physician/APN/PAxxHQR Enter your data directly into QNet Web-Based tool- Outpatient Web-Based Measures Annual Submission
May 15, 2025
CY 2024 data
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NHSN Measures
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Catheter Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR) for all units (1a) and ICUs excluding NICUs (1b)xx
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Catheter Associated Urinary Tract Infection (CAUTI) Rate for all units (2a) and ICUs excluding NICUs (2b)xx
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Catheter-associated urinary tract infection (CAUTI) standardized utilization ratio (SUR) in ICUs, medical and surgical units, excluding NICUs.xx
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CAUTI_DURCatheter-associated urinary tract infection (CAUTI) device utilization ratio
(DUR) in ICUs, medical and surgical units, excluding NICUs.		xx
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CLABSI_ICU_ICentral Line-Associated Bloodstream Infection (CLABSI) Rate for all units (2a) and ICUs excluding NICUs (2b)xx
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CLABSI_ICU_PCentral line-associated bloodstream infection (CLABSI) standardized infection ratio (SIR) in ICUs, medical and surgical units, including NICUs.xx
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CLABSI_SURCentral line-associated bloodstream infection (CLABSI) standardized utilization ratio (SUR) in ICUs, medical and surgical units, including NICUs.xx
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CLABSI_DURCentral line-associated bloodstream infection (CLABSI) device utilization ratio (DUR) in ICUs, medical and surgical units, including NICUs.xx
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CDIFF_SIRHospital Onset Clostridium difficile (C. diff) Standardized Infection Ratio (SIR)xx
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MRSA_SIRMethicillin-resistant Staphylococcus aureus (MRSA) standardized infection ratio (SIR), facility wide.xx
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Administrative Claims Measures
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ADE_ANTICOAGAnticoagulant-related adverse drug events (ADE) per 1,000 acute inpatient admissions.x
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OPIOID_DOSE_DCPercentage of patients discharged who received a high-dose opioid prescription within seven days of discharge.x
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ADE_HYPOGLYCEMIAHospital harm - severe hypoglycemia.x
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NARCAN_DCPercentage of patients discharged with an opioid prescription who were prescribed naloxone within seven days of discharge.x
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ADE_OPIOID_RATEHospital acquired opioid related adverse drug events (ADEs) per 1,000 discharges among Medicare beneficiariesx
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SEPSIS_SHOCKPost-operative sepsis and septic shock (PSI-13).x
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PU_STAGE 3Pressure Ulcer Rate, Stage 3+ x
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SEPSIS_MORTAdult inpatient risk adjusted sepsis mortality rate (NQF 3215).x
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Health Equity Measures (HE)
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HE1 REaL Data Collectionx
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HE2Care Gap Identificationx
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HE3Disparity Reduction Goalsx
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HE4Board Representationx
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Health of Community
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Health information exchange, or HIE, ADT notification service, CCDA, Statewide Lab ResultManage the care of patient populations through data transmittal utilizing MIHIN.x
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Quality Inititaives
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Michigan Critical Access Hospital Quality Network participation Quarterly meeting participation x
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