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1 | RELEVANT MEASURES FOR MI PEER GROUP 5 CAHs January 2024 | |||||||||||||||||||||||||
2 | MBQIP https://www.ruralcenter.org/resources/data-reporting-and-use | |||||||||||||||||||||||||
3 | Global Measures | |||||||||||||||||||||||||
4 | Measure | Narrative | MBQIP | HQIC Measures | BCBSM | MICAH Recommended | Reported to | Submission Method | Deadlines | Status | ||||||||||||||||
5 | Hospital Commitment to Health Equity Measures | Structural 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 | x | x | FMT | HQR Secure Portal | Annual Submission Begins Spring 2024 Refelcting CY 2023 | New for 2024 | ||||||||||||||||||
6 | CAH Quality Infrastructure Implementation | Structural measure to Assess Hospital quality infrastrucutre based on 9 core elements | x | x | FMT | FMT Qualtrics Platform via link | Annual Submission Due 12/25/2024 | New for 2024 | ||||||||||||||||||
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8 | Patient Safety Measures | |||||||||||||||||||||||||
9 | HCP/IMM3 | Influenza Vaccine Coverage healthcare workers | x | x | National Healthcare Safety Network | Enter your data into NHSN | Annual Submission by May 15 | |||||||||||||||||||
10 | Antimicrobial Stewardship | Questions as Answered to inform whether the facility successfully implemented core elements. Leadership Accountability Drug Expertise Action Tracking Reporting Education | x | x | National Healthcare Safety Network | Enter your data into NHSN | Annual Submission | |||||||||||||||||||
11 | 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 | x | x | CMS | QRDA Category 1 file | Annual Submission | New for 2024 | ||||||||||||||||||
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13 | Patient Experience | |||||||||||||||||||||||||
14 | HCAHPS | x | x | HQR | 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 1Qtr - July 6 2Qtr - October 5 3rd Qtr - January 4 4th Qtr - April 5 | ||||||||||||||||||||
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16 | Care Coordination | |||||||||||||||||||||||||
17 | Hybrid All-Cause Readmissions | Hosptial level, all cause, risk standardized readmission measure that focuses on unplanned readmission 30 days of discharge from an acute hospitalization | x | x | HQR | Patient level file in QRDA 1 format | Annual Submission First Available Reporting is 9/30/2024 for encounter period 7/1/2023 - 6/30/2024 | New for 2024 | ||||||||||||||||||
18 | 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. | x | x | HQR | Chart Abstraction Numerator and Denominator Submission | Annual Submission Calendar Year Jan 1 - Dec 31 First Available Reporting is 5/15/2024 for CY 2023 Reporting required 2025 | New for 2024 | ||||||||||||||||||
19 | 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. | x | x | HQR | Chart Abstraction Numerator and Denominator Submission via Web based data form | Annual Submission Calendar Year Jan 1 - Dec 31 First available reporting is 5/15/2024 for CY 2023 Reporting required 2025 | New for 2024 | ||||||||||||||||||
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21 | Emergency Department | |||||||||||||||||||||||||
22 | 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. | x | x | MCRH | Enter your data into the ED Transfer Communication Data Collection Tool and submit to Crystal Barter | Quarterly Submission 1Qtr - to Crystal by April 30th 2Qtr - to Crystal by July 31st 3Qtr - to Crystal by October 31st 4Qtr - to Crystal by January 31st | |||||||||||||||||||
23 | OP-18 Time from Arrival to Departure | Medican time from Emergency Department arrival to the time of departure from the emergency room for patients discharged from the ED. | x | x | HQR | Core Measures Vendor uploads your data to QNet or enter your data directly in the QNet CART | Quarterly Submission 1Qtr - August 1 2Qtr - November 1 3Qtr - February 1 4Qtr - May 1 | |||||||||||||||||||
24 | OP-22 Left without Being Seen | Percent of Patients who leave the Emergency Department without being evaluated by a physician/APN/PA | x | x | HQR | Enter your data directly into QNet Web-Based tool- Outpatient Web-Based Measures | Annual Submission Due May 15th Note: You are entering for the Payment Year (PY) two years ahead (i.e. entering 2018 data for PY 2020) | |||||||||||||||||||
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26 | NHSN Measures | |||||||||||||||||||||||||
27 | Catheter Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR) for all units (1a) and ICUs excluding NICUs (1b) | x | x | |||||||||||||||||||||||
28 | Catheter Associated Urinary Tract Infection (CAUTI) Rate for all units (2a) and ICUs excluding NICUs (2b) | x | x | |||||||||||||||||||||||
29 | Catheter-associated urinary tract infection (CAUTI) standardized utilization ratio (SUR) in ICUs, medical and surgical units, excluding NICUs. | x | x | |||||||||||||||||||||||
30 | CAUTI_DUR | Catheter-associated urinary tract infection (CAUTI) device utilization ratio (DUR) in ICUs, medical and surgical units, excluding NICUs. | x | x | ||||||||||||||||||||||
31 | CLABSI_ICU_I | Central Line-Associated Bloodstream Infection (CLABSI) Rate for all units (2a) and ICUs excluding NICUs (2b) | x | x | ||||||||||||||||||||||
32 | CLABSI_ICU_P | Central line-associated bloodstream infection (CLABSI) standardized infection ratio (SIR) in ICUs, medical and surgical units, including NICUs. | x | x | ||||||||||||||||||||||
33 | CLABSI_SUR | Central line-associated bloodstream infection (CLABSI) standardized utilization ratio (SUR) in ICUs, medical and surgical units, including NICUs. | x | x | ||||||||||||||||||||||
34 | CLABSI_DUR | Central line-associated bloodstream infection (CLABSI) device utilization ratio (DUR) in ICUs, medical and surgical units, including NICUs. | x | x | ||||||||||||||||||||||
35 | CDIFF_SIR | Hospital Onset Clostridium difficile (C. diff) Standardized Infection Ratio (SIR) | x | x | ||||||||||||||||||||||
36 | MRSA_SIR | Methicillin-resistant Staphylococcus aureus (MRSA) standardized infection ratio (SIR), facility wide. | x | x | ||||||||||||||||||||||
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38 | Administrative Claims Measures | |||||||||||||||||||||||||
39 | ADE_ANTICOAG | Anticoagulant-related adverse drug events (ADE) per 1,000 acute inpatient admissions. | x | |||||||||||||||||||||||
40 | OPIOID_DOSE_DC | Percentage of patients discharged who received a high-dose opioid prescription within seven days of discharge. | x | |||||||||||||||||||||||
41 | ADE_HYPOGLYCEMIA | Hospital harm - severe hypoglycemia. | x | |||||||||||||||||||||||
42 | NARCAN_DC | Percentage of patients discharged with an opioid prescription who were prescribed naloxone within seven days of discharge. | x | |||||||||||||||||||||||
43 | ADE_OPIOID_RATE | Hospital acquired opioid related adverse drug events (ADEs) per 1,000 discharges among Medicare beneficiaries | x | |||||||||||||||||||||||
44 | SEPSIS_SHOCK | Post-operative sepsis and septic shock (PSI-13). | x | |||||||||||||||||||||||
45 | PU_STAGE 3 | Pressure Ulcer Rate, Stage 3+ | x | |||||||||||||||||||||||
46 | SEPSIS_MORT | Adult inpatient risk adjusted sepsis mortality rate (NQF 3215). | x | |||||||||||||||||||||||
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48 | Health Equity Measures (HE) | |||||||||||||||||||||||||
49 | HE1 | REaL Data Collection | x | |||||||||||||||||||||||
50 | HE2 | Care Gap Identification | x | |||||||||||||||||||||||
51 | HE3 | Disparity Reduction Goals | x | |||||||||||||||||||||||
52 | HE4 | Board Representation | x | |||||||||||||||||||||||
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54 | Health of Community | |||||||||||||||||||||||||
55 | Health information exchange, or HIE, ADT notification service, CCDA, Statewide Lab Result | Manage the care of patient populations through data transmittal utilizing MIHIN. | x | |||||||||||||||||||||||
56 | Quality Inititaives | |||||||||||||||||||||||||
57 | Michigan Critical Access Hospital Quality Network participation | Quarterly meeting participation | x | |||||||||||||||||||||||
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