Specifications Manual for National Hospital Inpatient Quality Measures

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

Release Notes:

Table of Contents - Version 3.0

Table of Contents

Acknowledgement

Introduction

Using the Specifications Manual for National Hospital Inpatient Quality Measures

N/A

i

viii

Section 1

Data Dictionary

Introduction to the Data Dictionary

Alphabetical Data Dictionary

1-1

1-9

Section 2

Measurement Information

2.1

Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction National Hospital Inpatient Quality Measures

AMI Data Element List

Acute Myocardial Infarction (AMI) Initial Patient Population

AMI Initial Patient Population Algorithm

AMI Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-7, AMI-7a,

AMI-8, AMI-8a, AMI-9, AMI-T1a, AMI-T2

AMI-1

AMI-2

AMI-4

AMI-5

AMI-6

AMI-1-1

2.2

Heart Failure (HF)

Heart Failure National Hospital Inpatient Quality Measures

HF Data Element List

Heart Failure (HF) Initial Patient Population

HF Initial Patient Population Algorithm

HF Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

HF-1, HF-2, HF-3, HF-4

HF-1

HF-2

HF-3

HF-4

HF-5

HF-1-1

2.3

Pneumonia (PN)

Pneumonia National Hospital Inpatient Quality Measures

PN Data Element List

Pneumonia (PN) Initial Patient Population

PN Initial Patient Population Algorithm

PN Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5c,

PN-6, PN-6a, PN-6b, PN-7

PN-1

PN-2

PN-4

PN-5

PN-6

PN-1-1

Specifications Manual for National Hospital Inpatient Quality Measures

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

Table of Contents (cont.)

Section 2

Measurement Information (cont.)

2.4

Surgical Care Improvement Project (SCIP)

Surgical Care Improvement Project National Hospital Inpatient Quality Measures

SCIP Data Element List

Surgical Care Improvement Project (SCIP) Initial Patient Population

SCIP Initial Patient Population Algorithm

SCIP Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

SCIP Infection Module

SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6,

SCIP-Inf-9, SCIP-Inf-10

SCIP Cardiac Module

SCIP-Card-2

SCIP VTE Module

SCIP-VTE-1, SCIP-VTE-2

SCIP-1

SCIP-3

SCIP-5

SCIP-7

SCIP-9

SCIP-1-1

2.5

Pregnancy and Related Conditions (PR)

Pregnancy and Related Conditions National Hospital Inpatient Quality Measures

PR Data Element List

Pregnancy and Related Conditions (PR) Initial Patient Population

PR Initial Patient Population Algorithm

PR Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

PR-1, PR-2, PR-3

PR-1

PR-2

PR-3

PR-4

PR-5

PR-1-1

2.6

Children’s Asthma Care (CAC)

Children’s Asthma Care National Hospital Inpatient Quality Measures

CAC Data Element List

Children’s Asthma Care (CAC) Initial Patient Population

CAC Initial Patient Population Algorithm

CAC Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

CAC-1, CAC-2, CAC-3

CAC-1

CAC-2

CAC-3

CAC-4

CAC-5

CAC-1-1

2.7

Venous Thromboembolism (VTE)

Venous Thromboembolism National Hospital Inpatient Quality Measures

VTE Data Element List

Venous Thromboembolism (VTE) Initial Patient Population

VTE Initial Patient Population Algorithm

VTE Sample Size Requirement

Measure Information Form (MIF) and Flowchart (Algorithm)

VTE-1, VTE-2, VTE-3, VTE-4, VTE-5, VTE-6

VTE-1

VTE-2

VTE-4

VTE-5

VTE-7

VTE-1-1

2.8

Stroke (STK)

Stroke National Hospital Inpatient Quality Measures

STK Data Element List

Stroke (STK) Initial Patient Population

STK Initial Patient Population Algorithm

STK Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

STK-1, STK-2, STK-3, STK-4, STK-5, STK-6, STK-8, STK-10

STK-1

STK-2

STK-4

STK-5

STK-6

STK-1-1

Specifications Manual for National Hospital Inpatient Quality Measures

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

Table of Contents (cont.)

2.9

Emergency Department (ED)

Emergency Department National Hospital Inpatient Quality Measures

ED Data Element List

Emergency Department (ED) Initial Patient Population

ED Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm)

ED-1, ED-2

ED-1

ED-2

ED-4

ED-5

ED-1-1

Section 3

Missing and Invalid Data

3-1

Section 4

Population and Sampling Specifications

4-1

Section 5

Reserved for Future Use

5-1

Section 6

Reserved for Future Use

6-1

Section 7

Reserved for Future Use

7-1

Section 8

Reserved for Future Use

8-1

Section 9

Data Transmission

Data Transmission Introduction

Joint Commission Data Transmission

Information The Joint Commission Provides To ORYX® Vendors

CMS Data Transmission

CMS and Joint Commission Guidelines for Submission of Data

• CMS and Joint Commission Guidelines for Submission of Hospital Clinical Data

• CMS and Joint Commission Guidelines for Submission of Hospital Initial Patient Population Data

Transmission Alphabetical Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Hospital Clinical Data XML File Layout

Hospital Initial Patient Population Data XML File Layout

9-1

9-1

9-5

9-7

9-8

9-8

9-16

9-19

9-38

9-45

1

1

Section 10

CMS Outcome Measures (Claims Based)

10.1

Introduction Risk Standardized Mortality Measures

MORT-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality

MORT-30-HF: Heart Failure (HF) 30-Day Mortality

MORT-30-PN: Pneumonia (PN) 30-Day Mortality

10-1

10-2

10-7

10-12

10.2

Introduction Risk Standardized Readmission Measures

READM-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Readmission

READM-30-HF: Heart Failure (HF) 30-day Readmission

READM-30-PN: Pneumonia (PN) 30-Day Readmission

10-17

10-18

10-24

10-29

Specifications Manual for National Hospital Inpatient Quality Measures

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

Table of Contents (cont.)

Appendices

A.

ICD-9-CM Code Tables

AMI, CAC, ED, HF, PN, PR, SCIP, STK, VTE

Appendix A-1

B.

Reserved for Future Use

Appendix B-1

C.

Medication Tables

Appendix C-1

D.

Glossary of Terms

Appendix D-1

E.

Overview of Measure Information Form and Flowchart Formats for Collected Measures

Appendix E-1

F.

Measure Name Crosswalk

Appendix F-1

G.

Resources

Appendix G-1

H.

Miscellaneous Tables

Appendix H-1