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Title: Meaningful Use - Medicare and Medicaid EHR for Hospitals and
CAHs (Critical Access Hospitals)
Created by: Anisha Dharshi
Organization: National Quality Forum
Created on: Feb 13, 2012
Report generated by the Quality Positioning System
http://www.qualityforum.org/QPS
Quality Positioning System
Portfolio Report Table of Contents
Portfolio Details ............................................................................................................... 8
Measure Summary Table (NQF-endorsed®) .................................................................. 9
Measure Summary Table (No Longer NQF-endorsed®) ............................................... 21
Measure Details (NQF-endorsed®)............................................................................... 24
Measure Details (No Longer NQF-endorsed®) ............................................................. 58
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Meaningful Use - Medicare and Medicaid EHR for Hospitals and CAHs
(Critical Access Hospitals)
Portfolio Details
Short Description
This portfolio contains the Meaningful Use Stage I measures for hospitals and CAHs
(Critical Access Hospitals) that are NQF-endorsed. For questions or comments, contact
your local Regional Extension Center (http://www.regionalextensioncenters.com/)
Relevant Website(s)
Number of NQF-endorsed® measures included in portfolio: 11
Date portfolio was created: Feb 13, 2012
Date portfolio was last updated: Feb 14, 2012
Owner Name: Anisha Dharshi
Owner Organization: National Quality Forum
Portfolio Collaborators: None
Portfolio Notes
Public: None
Owner Keyword Search Terms: Meaningful Use, Hospital, critical access
Portfolio Location: http://www.qualityforum.org/QPS/QPSTool.aspx?p=575
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
8
Meaningful Use - Medicare and Medicaid EHR for Hospitals and CAHs
(Critical Access Hospitals)
Measure Summary Table (NQF-endorsed®)
The following is the list of the 11 NQF-endorsed® measure(s) included within this
portfolio.
Row
Measure Title
NQF #
Measure Description
Steward
1
Venous
Thromboembolis
m Prophylaxis
0371
This measure assesses the number
of patients who received venous
thromboembolism (VTE)
prophylaxis or have documentation
why no VTE prophylaxis was given
the day of or the day after hospital
admission or surgery end date for
surgeries that start the day of or the
day after hospital admission. This
measure is part of a set of six
nationally implemented prevention
and treatment measures that
address VTE (VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
Receiving UFH with
Dosages/Platelet Count Monitoring,
VTE-5: VTE Warfarin Therapy
Discharge Instructions and VTE-6:
The Joint
Commissio
n
Hospital Acquired PotentiallyPreventable VTE) that are used in
The Joint Commission’s
accreditation process.
1.1
Venous
Thromboembolis
m Prophylaxis
1.2
Venous
Thromboembolis
m Prophylaxis
3052
Not endorsed as an individual
measure
The Joint
Commissio
n
This measure assesses the number
of patients who received venous
thromboembolism (VTE)
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
9
Row
Measure Title
NQF #
Measure Description
Steward
prophylaxis or have documentation
why no VTE prophylaxis was given
the day of or the day after hospital
admission or surgery end date for
surgeries that start the day of or the
day after hospital admission. This
measure is part of a set of six
nationally implemented prevention
and treatment measures that
address VTE (VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
Receiving UFH with
Dosages/Platelet Count Monitoring,
VTE-5: VTE Warfarin Therapy
Discharge Instructions and VTE6:<br />Hospital Acquired
Potentially-Preventable VTE) that
are used in The Joint Commission’s
accreditation process.
2
Intensive Care
Unit Venous
Thromboembolis
m Prophylaxis
0372
This measure assesses the number
of patients who received venous
thromboembolism (VTE)
prophylaxis or have documentation
why no VTE prophylaxis was given
the day of or the day after the initial
admission (or transfer) to the
Intensive Care Unit (ICU) or
surgery end date for surgeries that
start the day of or the day after ICU
admission (or transfer). This
measure is part of a set of six
prevention and treatment measures
that address VTE (VTE-1: VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
10
Row
Measure Title
NQF #
Measure Description
Steward
Receiving UFH with
Dosages/Platelet Count Monitoring
by Protocol, VTE-5: VTE Warfarin
Therapy Discharge Instructions and
VTE-6: Hospital Acquired
Potentially-Preventable VTE).
2.1
Intensive Care
Unit Venous
Thromboembolis
m Prophylaxis
2.2
Intensive Care
Unit Venous
Thromboembolis
m Prophylaxis
3
Venouse
Thromboembolis
m Patients with
Antocoagulation
Not endorsed as an individual
measure
The Joint
Commissio
n
3053
This measure assesses the number
of patients who received venous
thromboembolism (VTE)
prophylaxis or have documentation
why no VTE prophylaxis was given
the day of or the day after the initial
admission (or transfer) to the
Intensive Care Unit (ICU) or
surgery end date for surgeries that
start the day of or the day after ICU
admission (or transfer). This
measure is part of a set of six
prevention and treatment measures
that address VTE (VTE-1: VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
Receiving UFH with
Dosages/Platelet Count Monitoring
by Protocol, VTE-5: VTE Warfarin
Therapy Discharge Instructions and
VTE-6: Hospital Acquired
Potentially-Preventable VTE).
The Joint
Commissio
n
0373
This measure assesses the number
of patients diagnosed with
confirmed VTE who received an
overlap of Parenteral (intravenous
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
11
Row
Measure Title
NQF #
Overlap Therapy
4
STK 02:
Discharged on
Antithrombotic
Therapy
Measure Description
Steward
[IV] or subcutaneous [subcu])
anticoagulation and warfarin
therapy. For patients who received
less than five days of overlap
therapy, they should be discharged
on both medications or have a
Reason for Discontinuation of
Parenteral Therapy. Overlap
therapy should be administered for
at least five days with an
international normalized ratio (INR)
greater than or equal to 2.0 prior to
discontinuation of the parenteral
anticoagulation therapy, or INR less
than 2.0 but discharged on both
medications or have a Reason for
Discontinuation of Parenteral
Therapy. This measure is part of a
set of six prevention and treatment
measures that address VTE (VTE1: VTE Prophylaxis, VTE-2: ICU
VTE Prophylaxis, VTE-4: VTE
Patients Receiving UFH with
Dosages/Platelet Count Monitoring,
VTE-5: Warfarin Therapy Discharge
Instructions and VTE-6: Hospital
Acquired Potentially-Preventable
VTE).
0435
This measure captures the
proportion of ischemic stroke
patients prescribed antithrombotic
therapy at hospital discharge.
The Joint
Commissio
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-3:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
12
Row
Measure Title
NQF #
Measure Description
Steward
Anticoagulation Therapy for Atrial
Fibrillation/Flutter, STK-4:
Thrombolytic Therapy,STK-5:
Antithrombotic Therapy By End of
Hospital Day 2, STK-6 Discharged
on Statin Medication, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
4.1
STK 02:
Discharged on
Antithrombotic
Therapy
Not endorsed as an individual
measure
The Joint
Commissio
n
4.2
STK 02:
Discharged on
Antithrombotic
Therapy
3042
This measure captures the
The Joint
proportion of ischemic stroke
Commissio
patients prescribed antithrombotic
n
therapy at hospital discharge. <br
/><br />This measure is a part of a
set of eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-3:
Anticoagulation Therapy for Atrial
Fibrillation/Flutter, STK-4:
Thrombolytic Therapy,STK-5:
Antithrombotic Therapy By End of
Hospital Day 2, STK-6 Discharged
on Statin Medication, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
5
STK-03:
Anticoagulation
0436
This measure captures the
proportion of ischemic stroke
The Joint
Commissio
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
13
Row
Measure Title
NQF #
Therapy for Atrial
Fibrillation/Flutter
Measure Description
Steward
patients with atrial fibrillation/flutter
who are prescribed anticoagulation
therapy at hospital discharge.
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-4: Thrombolytic
Therapy, STK-5: Antithrombotic
Therapy By End of Hospital Day 2,
STK-6 Discharged on Statin
Medication, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
5.1
STK-03:
Anticoagulation
Therapy for Atrial
Fibrillation/Flutter
5.2
STK-03:
Anticoagulation
Therapy for Atrial
Fibrillation/Flutter
3043
Not endorsed as an individual
measure
The Joint
Commissio
n
This measure captures the
proportion of ischemic stroke
patients with atrial fibrillation/flutter
who are prescribed anticoagulation
therapy at hospital discharge. <br
/><br />This measure is a part of a
set of eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-4: Thrombolytic
Therapy, STK-5: Antithrombotic
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
14
Row
Measure Title
NQF #
Measure Description
Steward
Therapy By End of Hospital Day 2,
STK-6 Discharged on Statin
Medication, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
6
STK 04:
Thrombolytic
Therapy
0437
This measure captures the
proportion of acute ischemic stroke
patients who arrive at this hospital
within 2 hours of time last known
well for whom IV t-PA was initiated
at this hospital within 3 hours of
time last known well.
The Joint
Commissio
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
Therapy for Atrial Fibrillation/Flutter,
STK-5: Antithrombotic Therapy By
End of Hospital Day 2, STK-6
Discharged on Statin Medication,
STK-8: Stroke Education, and STK10: Assessed for Rehabilitation)
that are used in The Joint
Commission’s hospital accreditation
and Disease-Specific Care
certification programs.
6.1
STK 04:
Thrombolytic
Therapy
Not endorsed as an individual
measure
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
15
Row
Measure Title
NQF #
Measure Description
Steward
6.2
STK 04:
Thrombolytic
Therapy
3044
This measure captures the
The Joint
proportion of acute ischemic stroke Commissio
patients who arrive at this hospital
n
within 2 hours of time last known
well for whom IV t-PA was initiated
at this hospital within 3 hours of
time last known well. <br /><br
/>This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
Therapy for Atrial Fibrillation/Flutter,
STK-5: Antithrombotic Therapy By
End of Hospital Day 2, STK-6
Discharged on Statin Medication,
STK-8: Stroke Education, and STK10: Assessed for Rehabilitation)
that are used in The Joint
Commission’s hospital accreditation
and Disease-Specific Care
certification programs.
7
STK 05:
Antithrombotic
Therapy By End
of Hospital Day
Two
0438
This measure captures the
proportion of ischemic stroke
patients who had antithrombotic
therapy administered by end of
hospital day two (with the day of
arrival being day 1).
The Joint
Commissio
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
16
Row
Measure Title
NQF #
Measure Description
Steward
Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK6: Discharged on Statin Medication,
STK-8: Stroke Education, and STK10: Assessed for Rehabilitation)
that are used in The Joint
Commission’s hospital accreditation
and Disease-Specific Care
certification programs.
7.1
STK 05:
Antithrombotic
Therapy By End
of Hospital Day
Two
7.2
STK 05:
Antithrombotic
Therapy By End
of Hospital Day
Two
Not endorsed as an individual
measure
3045
The Joint
Commissio
n
This measure captures the
The Joint
proportion of ischemic stroke
Commissio
patients who had antithrombotic
n
therapy administered by end of
hospital day two (with the day of
arrival being day 1). <br /><br
/>This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK6: Discharged on Statin Medication,
STK-8: Stroke Education, and STK10: Assessed for Rehabilitation)
that are used in The Joint
Commission’s hospital accreditation
and Disease-Specific Care
certification programs.
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
17
Row
Measure Title
NQF #
Measure Description
Steward
8
STK-06:
Discharged on
Statin Medication
0439
This measure captures the
proportion of ischemic stroke
patients who are prescribed a statin
medication at hospital discharge.
The Joint
Commissio
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK5: Antithrombotic Therapy By End
of Hospital Day 2, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
8.1
STK-06:
Discharged on
Statin Medication
8.2
STK-06:
Discharged on
Statin Medication
3046
Not endorsed as an individual
measure
The Joint
Commissio
n
This measure captures the
proportion of ischemic stroke
patients who are prescribed a statin
medication at hospital discharge.
<br /><br />This measure is a part
of a set of eight nationally
implemented measures that
address stroke care (STK-1:
Venous Thromboembolism (VTE)
Prophylaxis, STK-2: Discharged on
Antithrombotic Therapy, STK-3:
Anticoagulation Therapy for Atrial
Fibrillation/Flutter, STK-4:
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
18
Row
Measure Title
NQF #
Measure Description
Steward
Thrombolytic Therapy, STK-5:
Antithrombotic Therapy By End of
Hospital Day 2, STK-8: Stroke
Education, and STK-10: Assessed
for Rehabilitation) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
9
STK-10:
Assessed for
Rehabilitation
0441
This measure captures the
proportion of ischemic or
hemorrhagic stroke patients
assessed for or who received
rehabilitation services during the
hospital stay.
The Joint
Commissio
n
This measure is a part of a set of
eight nationally implemented
measures that address stroke care
(STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2:
Discharged on Antithrombotic
Therapy, STK-3: Anticoagulation
Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK5: Antithrombotic Therapy By End
of Hospital Day 2, STK-6
Discharged on Statin Medication,
and STK-8: Stroke Education) that
are used in The Joint Commission’s
hospital accreditation and DiseaseSpecific Care certification
programs.
9.1
STK-10:
Assessed for
Rehabilitation
Not endorsed as an individual
measure
The Joint
Commissio
n
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
19
Row
Measure Title
NQF #
Measure Description
Steward
9.2
STK-10:
Assessed for
Rehabilitation
3047
This measure captures the
proportion of ischemic or
hemorrhagic stroke patients
assessed for or who received
rehabilitation services during the
hospital stay. <br /><br />This
measure is a part of a set of eight
nationally implemented measures
that address stroke care (STK-1:
Venous Thromboembolism (VTE)
Prophylaxis, STK-2: Discharged on
Antithrombotic Therapy, STK-3:
Anticoagulation Therapy for Atrial
Fibrillation/Flutter, STK-4:
Thrombolytic Therapy, STK-5:
Antithrombotic Therapy By End of
Hospital Day 2, STK-6 Discharged
on Statin Medication, and STK-8:
Stroke Education) that are used in
The Joint Commission’s hospital
accreditation and Disease-Specific
Care certification programs.
The Joint
Commissio
n
10
Median Time
from ED Arrival to
ED Departure for
Admitted ED
Patients
0495
Median time from emergency
department arrival to time of
departure from the emergency
room for patients admitted to the
facility from the emergency
department
Centers for
Medicare
and
Medicaid
Services
11
Admit Decision
Time to ED
Departure Time
for Admitted
Patients
0497
Median time from admit decision
time to time of departure from the
emergency department for
emergency department patients
admitted to inpatient status
Centers for
Medicare
and
Medicaid
Services
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
20
Meaningful Use - Medicare and Medicaid EHR for Hospitals and CAHs
(Critical Access Hospitals)
Measure Summary Table (No Longer NQF-endorsed®)
The following is the list of the 4 no longer NQF-endorsed® measure(s) included within
this portfolio.
Row
Measure Title
NQF #
Measure Description
Steward
1
Venous
Thromboembolis
m Patients
Recieving
Unfractionated
Heparin with
Dosages/Platelet
Count Monitoring
by Protocol or
Nomogram(Endor
0374
This measure assesses the number
of patients diagnosed with
confirmed venous
thromboembolism (VTE) who
received intravenous (IV)
unfractionated heparin (UFH)
therapy dosages AND had their
platelet counts monitored using
defined parameters such as a
nomogram or protocol. This
measure is part of a set of six
prevention and treatment measures
that address VTE (VTE-1: VTE
Prophylaxis, VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-5: VTE Warfarin
Therapy Discharge Instructions and
VTE-6: Incidence of PotentiallyPreventable VTE).
The Joint
Commissio
n
0375
This measure assesses the number
of patients diagnosed with
confirmed VTE that
The Joint
Commissio
n
sement Removed)
2
Venous
Thrmoboembolis
m Warfarin
Therapy
Discharge
Instructions(Endor
sement Removed)
are discharged on warfarin to
home, home with home health or
home hospice with written
discharge instructions that address
all four criteria: compliance issues,
dietary advice, follow-up
monitoring, and information about
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
21
Row
Measure Title
NQF #
Measure Description
Steward
the potential for adverse drug
reactions/interactions. This
measure is part of a set of six
prevention and treatment measures
that address VTE (VTE-1: VTE
Prophylaxis, VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
Receiving UFH with
Dosages/Platelet Count Monitoring
by Protocol and VTE-6: Incidence
of Potentially-Preventable VTE).
3
Incidence of
Potentially
Preventable
Venous
Thromboembolis
m(Endorsement
0376
This measure assesses the number
of patients with confirmed venous
thromboembolism (VTE) during
hospitalization (not present at
admission) who did not receive
VTE prophylaxis between hospital
admission and the day before the
VTE diagnostic testing order date.
This measure is part of a set of six
prevention and treatment measures
that address VTE (VTE-1: VTE
Prophylaxis, VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients
with Anticoagulation Overlap
Therapy, VTE-4: VTE Patients
Receiving UFH with
Dosages/Platelet Count Monitoring
by Protocol, and VTE-5: VTE
Warfarin Therapy Discharge
Instructions).
The Joint
Commissio
n
0440
This measure captures the
proportion of ischemic or
hemorrhagic stroke patients with
documentation that they or their
caregivers were given stroke
The Joint
Commissio
n
Removed)
4
STK-08: Stroke
Education(Endors
ement Removed)
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
22
Row
Measure Title
NQF #
Measure Description
Steward
education materials. This measure
is a part of a set of eight nationally
implemented measures that
address stroke care (STK-1:
Venous Thromboembolism (VTE)
Prophylaxis, STK-2: Discharged on
Antithrombotic Therapy, STK-3:
Anticoagulation Therapy for Atrial
Fibrillation/Flutter, STK-4:
Thrombolytic Therapy,STK-5:
Antithrombotic Therapy By End of
Hospital Day 2, STK-6 Discharged
on Statin Medication, and STK-10:
Assessed for Rehabilitation) that
are used in The Joint Commission’s
hospital accreditation and DiseaseSpecific Care certification
programs.
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
23
Meaningful Use - Medicare and Medicaid EHR for Hospitals and CAHs
(Critical Access Hospitals)
Measure Details (NQF-endorsed®)
0371
Venous Thromboembolism Prophylaxis
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsed
Last Updated Date: Dec 23, 2014
Corresponding Measures: 0371:2932,0371:3052
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients who received
venous thromboembolism (VTE) prophylaxis or have documentation why no VTE
prophylaxis was given the day of or the day after hospital admission or surgery end date
for surgeries that start the day of or the day after hospital admission. This measure is
part of a set of six nationally implemented prevention and treatment measures that
address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation
Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count
Monitoring, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6:
Hospital Acquired Potentially-Preventable VTE) that are used in The Joint
Commission’s accreditation process.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
24
Exclusions: See details in multiple formats
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities: Patient Safety
Actual/Planned Use:
Data Source: Laboratory, Other, Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly, Populations at Risk, Populations at Risk: Individuals with
multiple chronic conditions
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
25
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
Safety: Healthcare-associated Conditions
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
26
0372
Intensive Care Unit Venous Thromboembolism Prophylaxis
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsed
Last Updated Date: Dec 23, 2014
Corresponding Measures: 0372:2933,0372:3053
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients who received
venous thromboembolism (VTE) prophylaxis or have documentation why no VTE
prophylaxis was given the day of or the day after the initial admission (or transfer) to the
Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the
day after ICU admission (or transfer). This measure is part of a set of six prevention
and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-3: VTE
Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH
with Dosages/Platelet Count Monitoring by Protocol, VTE-5: VTE Warfarin Therapy
Discharge Instructions and VTE-6: Hospital Acquired Potentially-Preventable VTE).
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
Risk Adjustment: No
Harmonization Requested
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
27
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities: Patient Safety
Actual/Planned Use:
Data Source: Electronic Health Record (Only), Other, Paper Records, Pharmacy
Level of Analysis: Facility, Other
Target Population: Elderly, Populations at Risk, Populations at Risk: Individuals with
multiple chronic conditions
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
28
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
Safety: Healthcare-associated Conditions
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
29
0373
Venouse Thromboembolism Patients with Antocoagulation
Overlap Therapy
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsed
Last Updated Date: Dec 23, 2014
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients diagnosed with
confirmed VTE who received an overlap of Parenteral (intravenous [IV] or subcutaneous
[subcu]) anticoagulation and warfarin therapy. For patients who received less than five
days of overlap therapy, they should be discharged on both medications or have a
Reason for Discontinuation of Parenteral Therapy. Overlap therapy should be
administered for at least five days with an international normalized ratio (INR) greater
than or equal to 2.0 prior to discontinuation of the parenteral anticoagulation therapy, or
INR less than 2.0 but discharged on both medications or have a Reason for
Discontinuation of Parenteral Therapy. This measure is part of a set of six prevention
and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE
Prophylaxis, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count
Monitoring, VTE-5: Warfarin Therapy Discharge Instructions and VTE-6: Hospital
Acquired Potentially-Preventable VTE).
Numerator Statement: Patients who received overlap therapy:
Included Populations: Patients who received warfarin and parenteral anticoagulation:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
30
•
Five or more days, with an INR greater than or equal to 2 prior to discontinuation
of parenteral therapy OR
•
OR
Five or more days, with an INR less than 2 and discharged on overlap therapy
•
Less than five days and discharged on overlap therapy OR
•
With documentation of reason for discontinuation of overlap therapy OR
•
With documentation of a reason for no overlap therapy
Denominator Statement: Patients with confirmed VTE who received warfarin. The
target population includes patients discharged with an ICD-9-CM Principal or Other
Diagnosis Codes for VTE as defined in Table 7.03 or Table 7.04.
Exclusions: • Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients with Comfort Measures Only documented
• Patients enrolled in clinical trials
• Patients discharged to a health care facility for hospice care
• Patients discharged to home for hospice care
• Patients who expired
• Patients who left against medical advice
• Patients discharged to another hospital
• Patients without warfarin therapy during hospitalization
• Patients without VTE confirmed by diagnostic testing
Risk Adjustment: No
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
31
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities: Patient Safety
Actual/Planned Use:
Data Source: Electronic Health Record (Only), Imaging-Diagnostic, Paper Records,
Pharmacy
Level of Analysis: Facility, Other
Target Population: Elderly, Populations at Risk, Populations at Risk: Individuals with
multiple chronic conditions
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
32
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
Discharge
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
Safety: Healthcare-associated Conditions
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
33
0435
STK 02: Discharged on Antithrombotic Therapy
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed – Reserve
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0435:2832,0435:3042
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic stroke
patients prescribed antithrombotic therapy at hospital discharge.
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-3:
Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-4: Thrombolytic Therapy,STK5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin
Medication, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are
used in The Joint Commission’s hospital accreditation and Disease-Specific Care
certification programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
Risk Adjustment: No
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
34
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Primary Prevention, Safety: Complications
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
Measure Steward Copyright
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
35
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
Discharge
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
36
0436
STK-03: Anticoagulation Therapy for Atrial Fibrillation/Flutter
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed – Reserve
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0436:2833,0436:3043
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic stroke
patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at
hospital discharge.
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-2: Discharged
on Antithrombotic Therapy, STK-4: Thrombolytic Therapy, STK-5: Antithrombotic
Therapy By End of Hospital Day 2, STK-6 Discharged on Statin Medication, STK-8:
Stroke Education, and STK-10: Assessed for Rehabilitation) that are used in The Joint
Commission’s hospital accreditation and Disease-Specific Care certification programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
Risk Adjustment: No
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
37
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Primary Prevention, Safety: Complications
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
Measure Steward Copyright
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
38
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
Discharge
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
39
0437
STK 04: Thrombolytic Therapy
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0437:2834,0437:3044
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of acute ischemic stroke
patients who arrive at this hospital within 2 hours of time last known well for whom IV tPA was initiated at this hospital within 3 hours of time last known well.
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-2: Discharged
on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter,
STK-5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin
Medication, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are
used in The Joint Commission’s hospital accreditation and Disease-Specific Care
certification programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
40
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Care Coordination, Health and Functional Status: Change,
Primary Prevention, Safety: Complications
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
41
Measure Steward Copyright
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
2012 MAP Cardiovascular Family of Measures
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
42
0438
STK 05: Antithrombotic Therapy By End of Hospital Day Two
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed – Reserve
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0438:2835,0438:3045
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic stroke
patients who had antithrombotic therapy administered by end of hospital day two (with
the day of arrival being day 1).
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-2: Discharged
on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK-6: Discharged on Statin Medication, STK-8: Stroke
Education, and STK-10: Assessed for Rehabilitation) that are used in The Joint
Commission’s hospital accreditation and Disease-Specific Care certification programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
Risk Adjustment: No
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
43
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Primary Prevention, Safety: Complications
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
Measure Steward Copyright
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
44
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Partnership for Patients: All Measures
Partnership for Patients: Venous Thromboembolism (VTE)
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
45
0439
STK-06: Discharged on Statin Medication
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed – Reserve
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0439:2836,0439:3046
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic stroke
patients who are prescribed a statin medication at hospital discharge.
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-2: Discharged
on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK-5: Antithrombotic Therapy By End of Hospital Day
2, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are used in
The Joint Commission’s hospital accreditation and Disease-Specific Care certification
programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
Risk Adjustment: No
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
46
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Primary Prevention, Safety: Complications
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
Measure Steward Copyright
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
47
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
Discharge
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
48
0441
STK-10: Assessed for Rehabilitation
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsed – Reserve
Last Updated Date: Sep 23, 2016
Corresponding Measures: 0441:2837,0441:3047
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic or
hemorrhagic stroke patients assessed for or who received rehabilitation services during
the hospital stay.
This measure is a part of a set of eight nationally implemented measures that address
stroke care (STK-1: Venous Thromboembolism (VTE) Prophylaxis, STK-2: Discharged
on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter,
STK-4: Thrombolytic Therapy, STK-5: Antithrombotic Therapy By End of Hospital Day
2, STK-6 Discharged on Statin Medication, and STK-8: Stroke Education) that are used
in The Joint Commission’s hospital accreditation and Disease-Specific Care certification
programs.
Numerator Statement: See details in multiple formats
Denominator Statement: See details in multiple formats
Exclusions: See details in multiple formats
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
49
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Care Coordination, Health and Functional Status: Change
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Payment Program, Public Health/Disease Surveillance, Public
Reporting, Quality Improvement (external benchmarking to organizations), Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
50
Measure Steward Copyright
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
2012 MAP Cardiovascular Family of Measures
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
51
0495
Median Time from ED Arrival to ED Departure for Admitted ED
Patients
Measure Status
Endorsement Date: Oct 24, 2008
Endorsement Type: Endorsed
Last Updated Date: May 12, 2016
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: Centers for Medicare and Medicaid Services
Measure Description: Median time from emergency department arrival to time of
departure from the emergency room for patients admitted to the facility from the
emergency department
Numerator Statement: Continuous Variable Statement: Time (in minutes) from ED
arrival to ED departure for patients admitted to the facility from the emergency
department.
Denominator Statement: Continuous Variable Statement: Time (in minutes) from ED
arrival to ED departure for patients admitted to the facility from the emergency
department.
Exclusions: Patients who are not an ED Patient
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
52
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition:
Cross-Cutting Area: Care Coordination
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use:
Data Source: Electronic Health Record (Only), Other, Paper Records
Level of Analysis: Facility
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: Centers for Medicare and Medicaid Services
Measure Steward Email Address: [email protected]
Measure Steward URL:
https://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1
228890496583&blobheader=multipart%2Foctet-stream&blobheadername1=ContentDisposition&blobheadervalue1=attachment%3Bfilename%3D2.9_ED_v5_0b.pdf&blobco
l=urldata&blobtable=Mungo
Measure Disclaimer
Measure Steward Copyright
Found In Other Portfolio(s):
Communication & Care Coordination: Communication & Care Transitions
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
53
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
The Pennsylvania Health Care Quality Alliance Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
54
0497
Admit Decision Time to ED Departure Time for Admitted
Patients
Measure Status
Endorsement Date: Oct 24, 2008
Endorsement Type: Endorsed
Last Updated Date: Jun 10, 2016
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: Centers for Medicare and Medicaid Services
Measure Description: Median time from admit decision time to time of departure from
the emergency department for emergency department patients admitted to inpatient
status
Numerator Statement: Continuous Variable Statement: Time (in minutes) from admit
decision time to time of departure from the emergency department for admitted patients.
Denominator Statement: Continuous Variable Statement: Time (in minutes) from
admit decision time to time of departure from the emergency department for admitted
patients.
Exclusions: Patients who are not an ED Patient
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
55
Classification
Use in Federal Program: Hospital Compare, Hospital Inpatient Quality Reporting
Condition:
Cross-Cutting Area: Care Coordination
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use:
Data Source: Electronic Health Record (Only), Other, Paper Records
Level of Analysis: Facility
Target Population: Children, Elderly, Populations at Risk
Measure Steward Contact Information
Measure Steward Organization: Centers for Medicare and Medicaid Services
Measure Steward Email Address: [email protected]
Measure Steward URL:
https://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1
228890496583&blobheader=multipart%2Foctet-stream&blobheadername1=ContentDisposition&blobheadervalue1=attachment%3Bfilename%3D2.9_ED_v5_0b.pdf&blobco
l=urldata&blobtable=Mungo
Measure Disclaimer
Measure Steward Copyright
Found In Other Portfolio(s):
Communication & Care Coordination: Communication & Care Transitions
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
56
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
Pediatrics
The Pennsylvania Health Care Quality Alliance Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
57
Meaningful Use - Medicare and Medicaid EHR for Hospitals and CAHs
(Critical Access Hospitals)
Measure Details (No Longer NQF-endorsed®)
0374
Venous Thromboembolism Patients Recieving Unfractionated
Heparin with Dosages/Platelet Count Monitoring by Protocol
or Nomogram
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsement Removed
Last Updated Date: Oct 17, 2012
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients diagnosed with
confirmed venous thromboembolism (VTE) who received intravenous (IV)
unfractionated heparin (UFH) therapy dosages AND had their platelet counts monitored
using defined parameters such as a nomogram or protocol. This measure is part of a
set of six prevention and treatment measures that address VTE (VTE-1: VTE
Prophylaxis, VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation
Overlap Therapy, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6:
Incidence of Potentially-Preventable VTE).
Numerator Statement: Patients who have their IV UFH therapy dosages AND platelet
counts monitored according to defined parameters such as a nomogram or protocol.
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
58
Denominator Statement: Patients with confirmed VTE receiving IV UFH therapy. The
target population includes patients discharged with an ICD-9-CM Principal or Other
Diagnosis Codes for VTE as defined in Table 7.03 or Table 7.04.
Exclusions: •
Patients less than 18 years of age
•
Patients who have a length of stay greater than 120 days
•
Patients with Comfort Measures Only documented
•
Patients enrolled in clinical trials
•
Patients discharged to a health care facility for hospice care
•
Patients discharged to home for hospice care
•
Patients who expired
•
Patients who left against medical advice
•
Patients discharged to another hospital
•
Patients without UFH Therapy Administration
•
Patients without VTE confirmed by diagnostic testing
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program:
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
59
Actual/Planned Use: Public Reporting, Quality Improvement (external benchmarking to
organizations), Quality Improvement (Internal to the specific organization), Regulatory
and Accreditation Programs
Data Source: Claims (Only), Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
60
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
61
0375
Venous Thrmoboembolism Warfarin Therapy Discharge
Instructions
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsement Removed
Last Updated Date: Oct 17, 2012
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients diagnosed with
confirmed VTE that
are discharged on warfarin to home, home with home health or home hospice with
written discharge instructions that address all four criteria: compliance issues, dietary
advice, follow-up monitoring, and information about the potential for adverse drug
reactions/interactions. This measure is part of a set of six prevention and treatment
measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE Prophylaxis,
VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients
Receiving UFH with Dosages/Platelet Count Monitoring by Protocol and VTE-6:
Incidence of Potentially-Preventable VTE).
Numerator Statement: Patients with documentation that they or their caregivers were
given
written discharge instructions or other educational material about warfarin that
addressed all of the following:
1. compliance issues
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
62
2. dietary advice
3. follow-up monitoring
4. potential for adverse drug reactions and interactions
Denominator Statement: Patients with confirmed VTE discharged on warfarin therapy.
The target population includes patients discharged with an ICD-9-CM Principal or Other
Diagnosis Codes for VTE as defined in Table 7.03 or Table 7.04 that are discharged to
home, homecare or court/law enforcement or home for hospice care.
Please note: The allowable values of the data element Discharge Disposition are used
to designate which locations are included.
Exclusions: • Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients enrolled in clinical trials
• Patients without Warfarin Prescribed at Discharge
• Patients without VTE confirmed by diagnostic testing
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program:
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities:
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
63
Actual/Planned Use: Public Reporting, Quality Improvement (external benchmarking to
organizations), Quality Improvement (Internal to the specific organization), Regulatory
and Accreditation Programs
Data Source: Claims (Only), Electronic Health Record (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
64
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
65
0376
Incidence of Potentially Preventable Venous
Thromboembolism
Measure Status
Endorsement Date: May 15, 2008
Endorsement Type: Endorsement Removed
Last Updated Date: Dec 13, 2012
Corresponding Measures:
Measure Type: Outcome
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure assesses the number of patients with confirmed
venous thromboembolism (VTE) during hospitalization (not present at admission) who
did not receive VTE prophylaxis between hospital admission and the day before the
VTE diagnostic testing order date. This measure is part of a set of six prevention and
treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE
Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE
Patients Receiving UFH with Dosages/Platelet Count Monitoring by Protocol, and VTE5: VTE Warfarin Therapy Discharge Instructions).
Numerator Statement: Patients who received no VTE prophylaxis prior to the VTE
diagnostic
test order date
Denominator Statement: Patients who developed confirmed VTE during
hospitalization. The target population includes patients discharged with an ICD-9-CM
Secondary Diagnosis Codes for VTE as defined in Table 7.03 or Table 7.04.
Exclusions: . Patients less than 18 years of age
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page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
66
• Patients who have a length of stay greater than 120 days
• Patients with Comfort Measures Only documented
• Patients enrolled in clinical trials
• Patients with ICD-9-CM Principal Diagnosis Code of VTE as defined in Appendix A,
Table 7.03 or 7.04
• Patients with VTE Present at Admission
• Patients with reasons for not administering mechanical and pharmacologic prophylaxis
• Patients without VTE confirmed by diagnostic testing
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program:
Condition:
Cross-Cutting Area: Primary Prevention
Care Setting: Hospital
National Quality Strategy Priorities: Patient Safety
Actual/Planned Use: Public Reporting, Quality Improvement (external benchmarking to
organizations), Quality Improvement (Internal to the specific organization), Regulatory
and Accreditation Programs
Data Source: Claims (Only), Paper Records
Level of Analysis: Facility, Other
Target Population: Elderly
Measure Steward Contact Information
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
67
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures/
Measure Disclaimer
Measure Steward Copyright
The Specifications Manual for National Hospital Inpatient Quality Measures
(Specifications Manual) is the result of the collaborative efforts of the Centers for
Medicare & Medicaid Services (CMS) and The Joint Commission to publish a uniform
set of national hospital quality measures. A primary objective of this collaborative effort
is to promote and enhance the utility of these measures for all hospitals.
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in the QIO supported initiatives, the Hospital
Inpatient Quality Reporting Program, and Joint Commission accreditation; including
performance measures systems; are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The Specifications Manual for National Hospital Inpatient
Quality Measures [Version xx, Month, Year] is the collaborative work of the Centers for
Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is
periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Hospital Inpatient Quality
Measures must update their software and associated documentation based on the
published manual production timelines.
Found In Other Portfolio(s):
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
68
2012 MAP Safety Family of Measures
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
69
0440
STK-08: Stroke Education
Measure Status
Endorsement Date: Jul 31, 2008
Endorsement Type: Endorsement Removed
Last Updated Date: Nov 06, 2012
Corresponding Measures:
Measure Type: Process
Measure Format: measure
Measure Details
Measure Steward: The Joint Commission
Measure Description: This measure captures the proportion of ischemic or
hemorrhagic stroke patients with documentation that they or their caregivers were given
stroke education materials. This measure is a part of a set of eight nationally
implemented measures that address stroke care (STK-1: Venous Thromboembolism
(VTE) Prophylaxis, STK-2: Discharged on Antithrombotic Therapy, STK-3:
Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-4: Thrombolytic Therapy,STK5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin
Medication, and STK-10: Assessed for Rehabilitation) that are used in The Joint
Commission’s hospital accreditation and Disease-Specific Care certification programs.
Numerator Statement: Ischemic or hemorrhagic stroke patients with documentation
that they or their caregivers were given educational material addressing all of the
following:
1. Activation of emergency medical system
2. Need for follow-up after discharge
3. Medications prescribed at discharge
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page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
70
4. Risk factors for stroke
5. Warning signs and symptoms of stroke
Denominator Statement: Ischemic stroke or hemorrhagic stroke patients discharged
home
Exclusions: •
Less than 18 years of age
•
Length of Stay > 120 days
•
Comfort measures only documented
•
Enrolled in clinical trials related to stroke
•
Admitted for elective carotid intervention
Risk Adjustment: No
Harmonization Requested
Harmonization Action:
Measure(s) Considered in Harmonization Request:
Classification
Use in Federal Program:
Condition: Neurology: Stroke/Transient Ischemic Attack (TIA)
Cross-Cutting Area: Access to Care, Care Coordination, Person-and Family-Centered
Care, Population Health, Primary Prevention, Safety, Safety: Complications, Safety:
Medication
Care Setting: Hospital
National Quality Strategy Priorities: Effective Communication and Care Coordination
Actual/Planned Use: Public Health/Disease Surveillance, Public Reporting, Quality
Improvement (Internal to the specific organization), Regulatory and Accreditation
Programs
Data Source: Electronic Health Record (Only), Other, Paper Records
Level of Analysis: Facility, Other
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page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
71
Target Population: Elderly
Measure Steward Contact Information
Measure Steward Organization: The Joint Commission
Measure Steward Email Address: [email protected]
Measure Steward URL:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_
quality_measures.aspx
Measure Disclaimer
Measure Steward Copyright
No royalty or use fee is required for copying or reprinting this manual, but the following
are required as a condition of usage: 1) disclosure that the Specifications Manual is
periodically updated, and that the version being copied or reprinted may not be up-todate when used unless the copier or printer has verified the version to be up-to-date
and affirms that, and 2) users participating in Joint Commission accreditation, including
ORYX® vendors, are required to update their software and associated documentation
based on the published manual production timelines.
Found In Other Portfolio(s):
AIR Patient and Family Engagement Measures
Maine Health Management Coalition and Maine Quality Forum Publicly Reported
Measures
Meaningful use stage 1 ,NQF-endorsed Measures for Inpatient
MU stage 2 proposed Measures
NQF Portfolio Disclaimer: NQF does not endorse measure portfolios, which are lists of measures, created using QPS. See
page 2 for the full disclaimer regarding the creation and use of measure portfolios using QPS.
72