eCQMs for 2015 Reporting Period

Clinical Quality Measures and their electronic specifications as defined in the April 2014 update for Eligible Hospitals.

Measure Namesort descending Short Name CMS ID Domain NQF ID Measure Steward USHIK Version Links
Anticoagulation Therapy for Atrial Fibrillation/Flutter Stroke3 CMS71v4 Effective Clinical Care 0436 The Joint Commission Version Detail
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Antithrombotic Therapy By End of Hospital Day 2 Stroke5 CMS72v3 Effective Clinical Care 0438 The Joint Commission Version Detail
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Aspirin Prescribed at Discharge AMI2 CMS100v3 Effective Clinical Care 0142 Oklahoma Foundation for Medical Quality Version Detail
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Assessed for Rehabilitation Stroke10 CMS102v3 Communication and Care Coordination 0441 The Joint Commission Version Detail
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Discharged on Antithrombotic Therapy Stroke2 CMS104v3 Effective Clinical Care 0435 The Joint Commission Version Detail
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Discharged on Statin Medication Stroke6 CMS105v3 Effective Clinical Care 0439 The Joint Commission Version Detail
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Elective Delivery PC01 CMS113v3 Effective Clinical Care 0469 The Joint Commission Version Detail
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Exclusive Breast Milk Feeding BF CMS9v3 Effective Clinical Care 0480 The Joint Commission Version Detail
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Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI7a CMS60v3 Effective Clinical Care 0164 Oklahoma Foundation for Medical Quality Version Detail
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Healthy Term Newborn CMS185v3 Patient Safety 0716 California Maternal Quality Care Collaborative (CMQCC) Version Detail
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Hearing Screening Prior To Hospital Discharge EHDI_1a CMS31v3 Effective Clinical Care 1354 CDC National Center on Birth Defects and Developmental Disabilities Version Detail
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Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver HMPC CMS26v2 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Incidence of Potentially-Preventable Venous Thromboembolism VTE6 CMS114v3 Patient Safety None The Joint Commission Version Detail
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Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients PN6 CMS188v4 Efficiency and Cost Reduction Use of Healthcare Resources 0147 Centers for Medicare & Medicaid Services Version Detail
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Intensive Care Unit Venous Thromboembolism Prophylaxis VTE2 CMS190v3 Patient Safety 0372 The Joint Commission Version Detail
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Median Admit Decision Time to ED Departure Time for Admitted Patients ED2 CMS111v3 Person and Caregiver-Centered Experience Outcomes 0497 Centers for Medicare & Medicaid Services Version Detail
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Median Time from ED Arrival to ED Departure for Admitted ED Patients ED1 CMS55v3 Person and Caregiver-Centered Experience Outcomes 0495 Centers for Medicare & Medicaid Services Version Detail
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Median Time from ED Arrival to ED Departure for Discharged ED Patients ED3 CMS32v4 Communication and Care Coordination 0496 Centers for Medicare & Medicaid Services Version Detail
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Primary PCI Received Within 90 Minutes of Hospital Arrival AMI8a CMS53v3 Effective Clinical Care 0163 Oklahoma Foundation for Medical Quality Version Detail
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Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIPInf1 CMS171v4 Patient Safety 0527 Centers for Medicare & Medicaid Services Version Detail
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Prophylactic Antibiotic Selection for Surgical Patients SCIPInf2 CMS172v4 Efficiency and Cost Reduction Use of Healthcare Resources 0528 Centers for Medicare & Medicaid Services Version Detail
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Statin Prescribed at Discharge AMI10 CMS30v4 Effective Clinical Care 0639 Centers for Medicare & Medicaid Services Version Detail
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Stroke Education Stroke8 CMS107v3 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Thrombolytic Therapy Stroke4 CMS91v4 Effective Clinical Care 0437 The Joint Commission Version Detail
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Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIPInf9 CMS178v4 Patient Safety 0453 Centers for Medicare & Medicaid Services Version Detail
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Venous Thromboembolism Discharge Instructions VTE5 CMS110v3 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram VTE4 CMS109v3 Effective Clinical Care None The Joint Commission Version Detail
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Venous Thromboembolism Patients with Anticoagulation Overlap Therapy VTE3 CMS73v3 Effective Clinical Care 0373 The Joint Commission Version Detail
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Venous Thromboembolism Prophylaxis VTE1 CMS108v3 Patient Safety 0371 The Joint Commission Version Detail
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Recent Activity

Tuesday, May 17 2016

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    4:05pm EDT
    Changes to Measure Type
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    4:03pm EDT
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    4:02pm EDT
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    4:01pm EDT
    Changes to Measure Observations
     
    Time (in minutes) from ED arrival to ED departure for patients admitted to
     
    Time (in minutes) from ED arrival to ED departure for patients admitted to
     
    the facility from the emergency department.
     
    the facility from the emergency department.
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    4:01pm EDT
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    Changes to Guidance
     
    Numerator element guidance:
     
    Numerator element guidance:
     
     
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    This measure expects a PCI procedure within 90 minutes of hospital arrival.
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    This measure expects a PCI procedure within 90 minutes of hospital arrival.
     
    Those patients receiving PCI procedures greater than 90 minutes after arrival
     
    Those patients receiving PCI procedures greater than 90 minutes after arrival
     
    may be excluded from the denominator only if there is a documented reason for
     
    may be excluded from the denominator only if there is a documented reason for
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    4:00pm EDT
    Too many differences to list. See Revisions for details.
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    3:59pm EDT
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    3:58pm EDT
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    Changes to Guidance
     
    * Environmental control and control of other triggers: information on
     
    * Environmental control and control of other triggers: information on
     
    avoidance or mitigation of environmental and other triggers.
     
    avoidance or mitigation of environmental and other triggers.
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    In addition to the information outlined in the asthma action plan form (or
     
    In addition to the information outlined in the asthma action plan form (or
     
    telephone number and time frame for appointment for follow-up care (e.g.,
     
    telephone number and time frame for appointment for follow-up care (e.g.,
     
    7-10 days).
     
    7-10 days).
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    The home management plan of care can only be considered to comply with the
     
    The home management plan of care can only be considered to comply with the
     
    * Outpatient Services including...
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    3:58pm EDT
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    3:57pm EDT
    ...
    Changes to Initial Patient Population
     
    Pneumonia patients 18 years of age and older at the time of admission with a
     
    Pneumonia patients 18 years of age and older at the time of admission with a
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    discharge diagnosis of ICD-10-CM Hospital Measures-Principal Diagnosis Code
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    discharge diagnosis of ICD-10-CM Hospital Measures-Principal Diagnosis Code
     
    of pneumonia, OR ICD-10-CM Hospital Measures-Principal Diagnosis Code of
     
    of pneumonia, OR ICD-10-CM Hospital Measures-Principal Diagnosis Code of
     
    septicemia or respiratory failure (acute or chronic) and also a secondary
     
    septicemia or respiratory failure (acute or chronic) and also a secondary
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    Changes to Guidance
     
    Transfers from another hospital that is not part of the hospital's
     
    Transfers from another hospital that is not part of the hospital's
     
    organization are excluded since care may have been delivered in the other
     
    organization are excluded since care may have been delivered in the other
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    setting. The measure as specified for abstraction allowed determination of
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    3:56pm EDT
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    Changes to Measure Type
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    Changes to Guidance
     
    Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of
     
    Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of
     
    their additional electronic clinical quality measures (eCQMs) for meaningful
     
    their additional electronic clinical quality measures (eCQMs) for meaningful
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    use. The measure will no longer be maintained since the measure steward has
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    use. The measure will no longer be maintained since the measure steward has
     
    submitted a substantially changed measure to NQF for endorsement.
     
    submitted a substantially changed measure to NQF for endorsement.
     
     
     
    The very first step for this measure, identifying all term singleton infants
     
    The very first step for this measure, identifying all term singleton infants
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    can be surprisingly challenging. Some hospitals do not do a good job of
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    can be surprisingly challenging. Some hospitals do not do a good job of using
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    using the proper v-codes or DRGs so that clinical information such as
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    3:56pm EDT
    Changes to Measure Type
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    Changes to Guidance
     
     
     
    By convention, discharge date post /Encounter inpatient/ is used to describe
     
    By convention, discharge date post /Encounter inpatient/ is used to describe
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    the hospital discharge date. Where logic needs to indicate discharge (or
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    the hospital discharge date. Where logic needs to indicate discharge (or
     
    transfer) from one inpatient location to another, the logic uses /Transfer
     
    transfer) from one inpatient location to another, the logic uses /Transfer
     
    From/ or /Transfer To/ as the QDS data type.
     
    From/ or /Transfer To/ as the QDS data type.
     
     
     
     
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    3:55pm EDT
    Changes to Denominator Exclusions
     
    * Patients enrolled in clinical trials-this exclusion is limited to patients
     
    * Patients enrolled in clinical trials-this exclusion is limited to patients
     
    participating in a clinical trial for the same conditions as covered by
     
    participating in a clinical trial for the same conditions as covered by
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    the measure. Other clinical trials are not valid reasons for exclusion.
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    the measure. Other clinical trials are not valid reasons for exclusion.
     
    * Patients whose principal procedure occurred prior to the date of admission
     
    * Patients whose principal procedure occurred prior to the date of admission
     
    * Patients with physician/advanced practice nurse/physician assistant
     
    * Patients with physician/advanced practice nurse/physician assistant
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    3:55pm EDT
    Changes to Denominator Exclusions
     
    * Patients enrolled in clinical trials-this exclusion is limited to patients
     
    * Patients enrolled in clinical trials-this exclusion is limited to patients
     
    participating in a clinical trial for the same conditions as covered by
     
    participating in a clinical trial for the same conditions as covered by
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    the measure. Other clinical trials are not valid reasons for exclusion.
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    the measure. Other clinical trials are not valid reasons for exclusion.
     
    * Patients with physician/advanced practice nurse/physician assistant
     
    * Patients with physician/advanced practice nurse/physician assistant
     
    (physician/APN/PA) documented infection prior to surgical procedure of
     
    (physician/APN/PA) documented infection prior to surgical procedure of
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    3:54pm EDT
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    3:53pm EDT
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