PfP HEN Metrics and benchmarks

Adverse Event Area / Measure
Early Elective Delivery (EED) / 1. Perinatal Care (PC)-01 Elective Delivery (NQF 0469) / < 2 percent
OB-Other / OB Trauma (PSI-18 and PSI-19)
2. PSI-18 Vaginal deliveries with instrument
3. PSI-19Vaginal deliveries without instrument / PSI-18 – 8.486
PSI-19 – 1.370
Catheter-Associated Urinary Tract Infection (CAUTI) / 4. National Healthcare Safety Network (NHSN) CAUTI Outcome Measure (NQF 0138) Standardized Infection Ratio (SIR)
  • Intensive Care Unit (ICU) Units, excluding Neonatal Intensive Care Unit (NICU)
  • ICU + Other units
5. Catheter utilization ratio (catheter days per 10,000 patient days) / ICU CAUTI – 0.6
House wide CAUTI – 0.48
SIR – 0.63
Catheter Utilization ratio – not defined
Central Line-Associated Blood Stream Infection (CLABSI) / 6. NHSN CLABSI Outcome Measure (NQF 0139) (SIR)
  • ICU Units, including NICU
  • ICU + Other units
7. CLABSI utilization ratio (central line days per 10,000 patient days) / ICU CLABSI – 0.48
House wide CLABSI – 0.18
SIR – 0.32
Catheter Utilization ratio – not defined
Falls / 8. Falls with injury (NQF 0202) (NDNQI)
  • All acute care units
/ Falls – 0.5
Pressure Ulcers (PrUl) / 9. PrU rate, Stages 3+ (Agency for Healthcare Research & Quality [AHRQ] PSI-03)
10. PrU prevalence (hospital-acquired) (NQF 0201) (Stage 2+) (NDNQI) / PSI-3 (all payer) – 0.246
PSI-3 (Medicare) – 0.328
PrU Stage 2+ - 1.487
Venous Thromboembolism (VTE) / 11. Post-Operative pulmonary embolism (PE) or deep vein thrombosis (DVT) rate (AHRQ PSI-12) / PSI 12 (all payer) – 0.556
PSI 12 (Medicare) – 0.369
SSI / American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific SSI Outcome Measure (NQF 0753) (SIR)
12. Colon surgeries
13. Abdominal hysterectomy
14. Total hip replacements
15. Total knee replacements
Note: SSI national measurement considers all procedures; therefore, the HEN interventions and measurement shall cover multiple classes of surgeries / SSI SIR – Colon – 0.504
SSI SIR – Abd. Hyst – 0.6
SSI – TH – not defined
SSI – TK – not defined
Ventilator-Associated Event (VAE) / 16. Ventilator-Associated Condition [VAC]
17. Infection-Related Ventilator-Associated Complication (IVAC) / VAC – Not defined
IVAC – not defined
VAP – 0.66
VAP SIR – 0.6
ADE – INR / # INR readings >5/# of INR readings / 2% of INR readings >5
ADE – Glycemic / # BG readings <50/# of BG readings / BG readings – 3%
C. Difficile / NHSN CDI rate (CDI/10,000 pt. days) / CDI - 4.4
Readmissions / 30 day Medicare FFS All- Cause readmission (per 100 discharges)
30 day All Payer All- Cause readmission (per 100 discharges) / Medicare readmission – 15.26
All Payer readmission – 20% reduction from HEN Baseline (8.37)