Measure Use of ICD 9 or ICD 10 codes Use of ICD 9 or ICD 10 codes Section 1 Basic Hospital Information 12-months ending 12/31/2015 N/A 12-months ending 06/30/2016 N/A Section 2 Computerized Prescriber Entry (CPOE) Latest 3-months to survey submission N/A Latest 3-months prior to survey submission N/A Section 3 Evidence-Based Hospital Referral (AVR, AAA, Pancreatectomy, Esophagetcomy) 12-months or 24-months ending 09/30/2015 ICD-9 12-months or 24-months ending 09/30/2015 ICD-9 4A Maternity Care 9-months ending 09/30/2015 N/A 9-months ending 06/30/2016 N/A 4B Early Elective Deliveries 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4C NTSV Cesarean Section 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4D Incidence of Episiotomy 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4E Bilirubin Screening & DVT Prophylaxis 9-months ending 09/30/2015 N/A 9-months ending 06/30/2016 N/A 4F High-Risk Newborn Deliveries Volume: 12-months ending 09/30/2015 ICD-9 Volume: 12-months ending 09/30/2015 ICD-9 VON: Latest 12- or report N/A VON: Latest 12- or report N/A Antenatal Steroids: 9-months ending 09/30/2015 ICD-9 Antenatal Steroids: 9-months ending 06/30/2016 ICD-10 5 ICU Physician Staffing Latest 3-months prior to survey submission N/A Latest 3-months prior to survey submission N/A 6 National Quality Forum’s Safe Practices Latest 12- or 24-months prior to submission (see individual safe practice for specific reporting period) N/A Latest 12- or 24-months prior to submission (see individual safe practice for specific reporting period) N/A 7A Never Events Policy N/A N/A N/A N/A
SECTION 1: BASIC HOSPITAL INFORMATION This section includes questions and reference information for Section 1 Hospital Information. Please carefully review the questions, endnotes, and reference information (e.g., measure specifications, notes, and frequently asked questions) before you begin. Failure to review the reference information could result in inaccurate responses. Section 1: 2016 Basic Hospital Information Specifications: Hospitals that share a Medicare Provider Number are required to report by facility. Please carefully review . Reporting Time Period: 12 months For surveys submitted prior to September 1, 2016: 01/01/2015 – 12/31/2015 For surveys (re)submitted on or after September 1, 2016: 07/01/2015 – 06/30/2016 Reporting time period used: 01/01/2015 – 12/31/2015 07/01/2015 – 06/30/2016 Number of medical, surgical, and obstetric beds. Number of medical, surgical, and obstetric beds. Number of to your hospital. Number of beds. Number of beds. Number of .
If “yes,” but fewer than 10 cases met the inclusion criteria for the denominator, skip questions #8-10. Number of cases measured against the guideline, either all cases or a sufficient sample of them (denominator) ______ Number of cases in question #8 that adhere to the clinical process guideline (numerator) ______ Do the responses in questions #8 and #9 represent a sample of cases? Yes No 4F:High-Risk Deliveries High-Risk Deliveries Does your hospital ? If “no,” skip questions #2-17, and move on to the next section. Yes No Does your hospital operate a neonatal ICU, or is it with a hospital that operates a NICU, that admits or accepts transfers of ? If “no,” answer questions #12-17, and skip questions #3-11. If the NICU is co-located in another hospital and your hospital immediately transfers all complicated newborns there, answer question #3 and either questions #4-5 or #6-11 based on information pertaining to the co-located hospital’s NICU. Yes No Hospitals that participate in the Vermont Oxford Network (VON), and have a recent 12-month or 36-month report available, may elect to report your facility’s Volume (questions #4-5) OR the (questions #6-11). Hospitals that do not participate in the Vermont Oxford Network, should report your facility’s Volume (questions #4-5). Please indicate which measure the hospital will report on: If you elect to report on Volume, answer questions #4-5, and skip questions #6-11. If you elect to report on the VON National Performance Measure, skip questions #4-5, and report on questions #6-11. Volume VON National Performance Measure
Neonatal Intensive Care Unit(s) – Volume Specifications: See in the Maternity Care Reference Information on page 72. 12-month reporting time period used: 10/01/2014 - 09/30/2015 For the Reporting Time Period, how many very-low birth-weight babies were admitted to your hospital’s neonatal intensive care unit(s)? _______ Neonatal Intensive Care Unit(s) – National Performance Measurement Specifications: See in the Maternity Care Reference Information on page 73. Does your hospital participate in the Vermont Oxford Network performance reporting system for high-risk deliveries and did your hospital submit data for all such deliveries during the most recent 12-month period for which performance reports have been released? If “no,” please return to question #3 and select “Volume,” then complete questions #4 and #5. Yes No What is the most recent 12-month or 36-month reporting period for which VON performance results are available? Time period ending: __________ YYYY Format: 2015 From the report for that time period, what is your hospital’s volume? _______ From the same report, what was your hospital’s SMR 95% bound? _______ Format: 0.8 From the report for that time period, what was your hospital’s observed to expected ratio of morbidity or mortality (SMR shrunken)? _______ Format: 1.0 From the same report, what was your hospital’s SMR 95% bound? _______ Format: 1.2 Process Measure of Quality – Antenatal Steroids Specifications: See in the Maternity Care Reference Information on pages 74-75.
6G: Safe Practice # 19 Hand Hygiene 19.1, 19.4: How will institutions measure or monitor progress with this Safe Practice? The following elements may be monitored as part of a performance improvement project: Implementation of the nationally-approved hand hygiene guidelines as established by the Centers for Disease Control (CDC) Hospital-acquired infection rates as a pre- and post-test after the implementation of interventions, such as bedside dispensers or other equipment for hand decontamination made available to staff 19.4: Will use of the CDC guidelines for hand hygiene meet this Safe Practice? Yes. Please see: . 19.4b: Would a general hand hygiene “campaign” be enough to count as a formal performance improvement program? ? No. To meet this element, hospitals should be employing one or more of the following: technology systems to monitor hand hygiene compliance, use of secret observers, and measuring use of hand hygiene product. 6H: Safe Practice # 23 Prevention of Healthcare-Associated Complications in Ventilated Patients 23.1a and 23.2a: Which roles are included in senior administrative and clinical leadership? COO, CEO, CNO, CMO, Head of Pharmacy, and respiratory therapists. 23.3a: Which staff roles should receive education/knowledge transfer and skill development programs on ventilator use and its complications? Physicians, nurses, pharmacists, and respiratory therapists. 23.4c: Do ALL ventilated patients and/or their families need to be educated on prevention measures involved in the care of the ventilated patient? What if the patient is unconscious and has no family members? In that situation, it would be appropriate to document that the patient is unresponsive, has no family members, and therefore no opportunity for education. When the patient does not have family members, it would be appropriate to adopt a broader definition of “family” to include loved ones and those who will be caring for the patient. 23.4: How can pediatric hospitals address the expectations of the Action answer of this Safe Practice? The action expectations of this survey question may be satisfied by implementation and adoption of the Pediatric elements for patients 18 years and younger as outlined in this NQF Safe Practice Additional Specifications. Page Intentionally Left Blank
Does your hospital utilize personnel trained in ? Yes No Check all ICU types that were staffed and open during the reporting period: Medical Surgical Medical/Surgical Pediatric Medical Pediatric Medical/Surgical Pediatric Cardiothoracic Medical Cardiac Respiratory Surgical Cardiothoracic Neurologic Neurosurgical Burn Trauma NICU II/III NICU III Total number of central line days and central line-associated bloodstream infections in each ICU type during the reporting period as reported to the CDC/NHSN: 9a) Total number of central line days (denominator) 9b) Total number of central bloodstream infections (numerator) Medical Surgical Medical/Surgical Pediatric Medical Pediatric Medical/Surgical Pediatric Cardiothoracic Medical Cardiac Respiratory Surgical Cardiothoracic Neurologic Neurosurgical Burn Trauma NICU II/III <= 750 g 751 – 1,000 g 1,001 – 1,500 g 1,501 – 2,500 g >2,500 g NICU III <= 750 g 751 – 1,000 g 1,001 – 1,500 g 1,501 – 2,500 g >2,500 g