Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)

Last Updated: Version 4.3a Table of Contents Page Number

Acknowledgement N/A

Introduction i

Using the Specifications Manual for National Hospital Inpatient ix Quality Measures

Section 1 Data Dictionary

Introduction to the Data Dictionary 1-1 Alphabetical Data Dictionary 1-9

Section 2 Measurement Information 2.1 Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction National Hospital Inpatient Quality AMI-1 Measures AMI Data Element List AMI-2 Acute Myocardial Infarction (AMI) Initial Patient Population AMI-4 AMI Initial Patient Population Algorithm AMI-5 AMI Sample Size Requirements AMI-8 Measure Information Form (MIF) and Flowchart (Algorithm) AMI-1-1

AMI-1, AMI-2, AMI-3, AMI-5, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-10

2.2 Heart Failure (HF)

Heart Failure National Hospital Inpatient Quality Measures HF-1 HF Data Element List HF-2 Heart Failure (HF) Initial Patient Population HF-4 HF Initial Patient Population Algorithm HF-5 HF Sample Size Requirements HF-8 Measure Information Form (MIF) and Flowchart (Algorithm) HF-1-1 HF-1, HF-2, HF-3

2.3 Pneumonia (PN)

Pneumonia National Hospital Inpatient Quality Measures PN-1 PN Data Element List PN-2 Pneumonia (PN) Initial Patient Population PN-4 PN Initial Patient Population Algorithm PN-5 PN Sample Size Requirements PN-8 Measure Information Form (MIF) and Flowchart (Algorithm) PN-3a-1

PN-3a, PN-3b, PN-6, PN-6a, PN-6b 2.4 Surgical Care Improvement Project (SCIP)

Surgical Care Improvement Project National Hospital Inpatient SCIP-1 Quality Measures SCIP Data Element List SCIP-3 Surgical Care Improvement Project (SCIP) Initial Patient Population SCIP-6

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)

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SCIP Initial Patient Population Algorithm SCIP-8 SCIP Sample Size Requirements SCIP-12 Measure Information Form (MIF) and Flowchart (Algorithm) SCIP-1-1

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-2

2.5 Reserved for Future Use 2.6 Children’s Asthma Care (CAC)

Children’s Asthma Care National Hospital Inpatient CAC-1 Quality Measures CAC Data Element List CAC-2 Children’s Asthma Care (CAC) Initial Patient Population CAC-4 CAC Initial Patient Population Algorithm CAC-5 CAC Sample Size Requirements CAC-8 Measure Information Form (MIF) and Flowchart (Algorithm) CAC-1-1

CAC-1, CAC-2, CAC-3 2.7 Venous Thromboembolism (VTE)

Venous Thromboembolism National Hospital Inpatient VTE-1 Quality Measures VTE Data Element List VTE-2 Venous Thromboembolism (VTE) Initial Patient Population VTE-5 VTE Initial Patient Population Algorithm VTE-6 VTE Sample Size Requirement VTE-10 Measure Information Form (MIF) and Flowchart (Algorithm) VTE-1-1

VTE-1, VTE-2, VTE-3, VTE-4, VTE-5, VTE-6 2.8 Stroke (STK)

Stroke National Hospital Inpatient Quality Measures STK-1 STK Data Element List STK-2 Stroke (STK) Initial Patient Population STK-5 STK Initial Patient Population Algorithm STK-6 STK Sample Size Requirements STK-9 Measure Information Form (MIF) and Flowchart (Algorithm) STK-1-1

STK-1, STK-2, STK-3, STK-4, STK-5, STK-6, STK-8, STK-10 2.9 Global Initial Patient Population (ED, IMM, TOB, SUB)

Global National Hospital Inpatient Quality Measures Initial Patient Population GLB-1

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)

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2.10 Emergency Department (ED) Emergency Department National Hospital Inpatient Quality Measures ED-1 ED Data Element List ED-2 Emergency Department (ED) Initial Patient Population ED-4 ED Initial Patient Population Algorithm ED-4 ED Sample Size Requirements ED-4 Measure Information Form (MIF) and Flowchart (Algorithm) ED-1-1

ED-1, ED-2 Section 2.11 Prevention 2.11.1 Immunization (IMM)

Immunization National Hospital Inpatient Quality Measures IMM-1 Immunization Data Element List IMM-2 Immunization Initial Patient Population IMM-4 Immunization Initial Patient Population Algorithm IMM-4 Immunization Sample Size Requirements IMM-4 Measure Information Form (MIF) and Flowchart (Algorithm) IMM-1-1

IMM-1, IMM-2 2.11.2 Tobacco Treatment (TOB)

Tobacco Treatment National Hospital Inpatient Quality Measures TOB-1 Tobacco Treatment Data Element List TOB-2 Tobacco Treatment Initial Patient Population TOB-4 Tobacco Treatment Initial Patient Population Algorithm TOB-4 Tobacco Treatment Sample Size Requirements TOB-4 Measure Information Form (MIF) and Flowchart (Algorithm) TOB-1-1

TOB-1, TOB-2, TOB-3, TOB-4 2.11.3 Substance Use (SUB)

Substance Use National Hospital Inpatient Quality Measures SUB-1 Substance Use Data Element List SUB-2 Substance Use Initial Patient Population SUB-4 Substance Use Initial Patient Population Algorithm SUB-4 Substance Use Sample Size Requirements SUB-4 Measure Information Form (MIF) and Flowchart (Algorithm) SUB-1-1

SUB-1, SUB-2, SUB-3, SUB-4 Section 3 Missing and Invalid Data 3-1 Section 4 Population and Sampling Specifications 4-1 Sections 5 – 8 Reserved for Future Use N/A Section 9 Data Transmission

Data Transmission Introduction 9-1 Joint Commission Data Transmission 9-1 Information The Joint Commission Provides To ORYX® Vendors 9-6

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)

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CMS Data Transmission 9-7 CMS and Joint Commission Guidelines for Submission of Data 9-9 • CMS and Joint Commission Guidelines for 9-9

Submission of Hospital Clinical Data • CMS and Joint Commission Guidelines for Submission of 9-16

Hospital Initial Patient Population Data Transmission Alphabetical Data Dictionary 9-19 Transmission Data Processing Flow: Clinical 9-38 Transmission Data Processing Flow: Population and Sampling 9-46 Hospital Clinical Data XML File Layout 1 Hospital Initial Patient Population Data XML File Layout 1

Section 10 CMS Outcome Measures (Claims Based) 10.1 Introduction Risk Standardized Mortality Measures 10-1

MORT-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality 10-2 MORT-30-COPD: Chronic Obstructive Pulmonary Disease (COPD) 10-8 30-Day Mortality MORT-30-HF: Heart Failure (HF) 30-Day Mortality 10-14 MORT-30-PN: Pneumonia (PN) 30-Day Mortality 10-20 MORT-30-STR: Acute Ischemic Stroke 30-Day Mortality 10-26

10.2 Introduction Risk Standardized Readmission and Complication Measures 10-32

READM-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Readmission 10-34 READM-30-COPD: Chronic Obstructive Pulmonary Disease (COPD) 10-40 30-Day Readmission READM-30-HF: Heart Failure (HF) 30-Day Readmission 10-46 READM-30-HWR: Hospital-Wide 30-Day Readmission 10-53 READM-30-PN: Pneumonia (PN) 30-Day Readmission 10-60 READM-30-STR: Acute Ischemic Stroke 30-Day Readmission 10-67 READM-30-THA/TKA: THA/TKA 30-Day Readmission 10-73 COMP-THA/TKA: THA/TKA Complication 10-78

10.3 Agency for Healthcare Research and Quality (AHRQ) Measures 10-83 10.4 Healthcare Associated Infections (HAI) Measures 10-84 10.5 CMS AMI Episode-of-Care Payment Measure 10-86

PAYM-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Payment 10-87 10.6 Structural Measures 10-94

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)

Table of Contents (continued) Page Number Appendices A. ICD-9-CM Code Tables Appendix A-1

A.1 ICD-9-CM Code Tables AMI, CAC, ED, HF, IMM, PN, SCIP, STK, SUB, TOB, VTE A.2 Reserved for Future Use

B. Reserved for Future Use N/A C. Medication Tables Appendix C-1 D. Glossary of Terms Appendix D-1 E. Overview of Measure Information Form and Flowchart Formats Appendix E-1 F. Measure Name Crosswalk Appendix F-1 G. Resources Appendix G-1 H. Miscellaneous Tables Appendix H-1 P. Preview Section Appendix P-1