AEA / Minimum Participation / Full Participation[1] /
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives 2 points (not 3 points).
Maximum = 22 points /
Adverse Drug Events
(ADE) / Outcome Measure for Any One of the Following:
u Anticoagulant
u Opioid
u Glucose Control
u An overall measure of ADEs / Outcome Measures Meeting Either A or B:
A) Related to all three of: anticoagulant, opioid, and glucose control
OR
B) Related to two of anticoagulant, opioid, and glucose control
AND
A measure of overall ADEs or a different high-frequency ADE
Falls / Outcome Measure Including:
All falls with or without Injury / At least one outcome measure meeting either A or B:
A) All falls AND Injuries from Falls and Trauma (MCR FFS CMS HAC)
OR
B) All falls with injury (not limited to subset of patients with severe injuries)
Obstetrical – Earl Elective Deliveries
(OB-EED) / Outcome Measure Meeting A:
A) Joint Commission PC-01
Other Obstetrical
(OB-Other) / Outcome Measures Meeting A or B:
A) At least two of: AHRQ PSIs 17, 18, and 19[2]
OR
B) Reporting Obstetrical hemorrhage and preeclampsia treatment and management to prevent morbidity and mortality) / Outcome Measures Meeting A and B:
A) At least two of: AHRQ PSIs 17, 18, and 19
AND
B) Reporting Obstetrical hemorrhage and preeclampsia treatment and management to prevent morbidity and mortality)
Pressure Ulcers
(PrU) / Outcome Measure Including:
Stage 3 and higher PrUs / Outcome Measure Including:
Stage 2 and higher PrUs
AND
Stage 3 and greater PrUs subset
Surgical Site Infections
(SSI) / Outcomes Measures for 2 or More of the Following (separately or combined):
u Colon
u Hysterectomy
u Knee Replacement
u Hip Replacement
u Cardiac Surgeries (may be specific to a common subset of cardiac surgeries such as Coronary Artery Bypass Graft [CABG]) / Outcomes Measures for 4 or More of the Following (separately or combined):
u Colon
u Hysterectomy
u Knee Replacement
u Hip Replacement
u Cardiac Surgeries (may be specific to a common subset of cardiac surgeries such as CABG)
Ventilator-Associated Events
(VAE)
Adults Only / Outcome Measure Meeting A or B:
A) NHSN-defined Ventilator-acquired conditions (VACs) alone (“respiratory status component”) (ICU Only or All Units)
OR
B) At least one of:
· Infection-related Ventilator-Associated Complication (IVACs) (“infection/ inflammation component”) (ICU Only or All Units)
· Possible or Probable VAP (ICU Only or All Units) / Outcome Measures Meeting A and B:
A) NHSN-defined Ventilator-acquired conditions (VACs) alone (“respiratory status component”) (ICU Only and All Units)
AND
B) At least one of:
· Infection-related Ventilator-Associated Complication (IVACs) (“infection/ inflammation component”) (ICU Only and All Units)
· Possible or Probable VAP (ICU Only and All Units)
Catheter-Associated Urinary Tract Infection
(CAUTI) / Outcome Measure Meeting A or B:
A) NHSN/NDNQI CAUTI Rate (ICU)
OR
B) NHSN/NDNQI CAUTI Rate (All units) / Outcome Measures Meeting A and one of B:
A) NHSN/NDNQI CAUTI Rate including both:
· ICU/NICU
· General units (including specialty units) measured separately and/or combined
B) A catheter utilization measure
· A utilization ratio (catheter days per 10,000 patient days, or similar with other denominator)
OR
· ED Catheterization rate
Central Line Associated Blood Stream Infection
(CLABSI) / Outcome Measure:
u NHSN/NDNQI CLABSI Rate ICU/NICU only
OR
u Days since last CLABSI / Outcome Measures Meeting A and B:
A) NHSN/NDNQI CLABSI Rate including all:
· ICU/NICU
· General units (including specialty units) measured separately and/or combined
· For larger hospitals, a utilization ratio (central line days per 10,000 patient days)
AND
B) Other HEN-defined measure that applies to small hospitals (<100 beds) (e.g., days since last CLABSI)
Note: For larger hospitals, measurement of house-wide CLABSI rate may use an alternative specification, such as a measure with denominator of patient days.
Venous Thromboembolism
(VTE) / Outcome Measure meeting either A or B:
A) AHRQ PSI-12
OR
B) Potentially preventable VTE Rate (meaningful use or CMS definition, VTE-6) / Outcome Measures Meeting A and B:
B) AHRQ PSI-12
AND
C) Potentially preventable VTE Rate (meaningful use or CMS definition, VTE-6)
Readmissions / Outcome Measures:
Only diagnosis-specific readmission rates / Outcome Measures Meeting A and B:
A) Broad measure, including any of the following:
· 30-day all payer all cause readmissions
· 30-day potentially preventable readmissions
· An observed-to-expected ratio of 30-day readmissions for all payers.
AND
B) HEN indicates if measure counts only readmissions to the hospital of the index admission or to any hospital; and any exclusions (e.g. planned readmissions) used
[1] Includes either submission or attestation that at least one corresponding process measure is being collected per AEA with the exception of EED which is a required process measure for birthing hospitals
[2] PSI 17 – Birth Trauma Rate – Injury to Neonate; PSI 18 – Obstetric Trauma Rate – Vaginal Delivery With Instrument; PSI 19 – Obstetric Trauma Rate – Vaginal Delivery without Instrument