Hours of physical constraint The number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint. Nominated by Dana Safran, BCBSMA Priority Area Appropriateness of hospital-based care Steward Joint Commission NQF Endorsed (0640) Summary Addresses SQAC Priority Area NQF-Endorsed or in a National Set Minimum Scores Overall Score Rating    15 (Average 3.75) Strong Recommended for inclusion Detailed Measure Evaluation Reliability and Validity Minimum Score: 2 3 All of the HBIPS measures have undergone a rigorous process of public comment, alpha testing and broad-scale pilot testing and are recognized by the field as important indicators of hospital-based inpatient psychiatric care. Amenability to Targeted Improvement No Minimum Score 4 There are documented interventions that facilities can take to reduce use of physical constraints. Ease of Measurement Minimum 1 4 Requires chart review, but is already publicly reported by CMS. Field Implementation Minimum 1 4 Already used and publicly reported by CMS on a facility level. References NQF Measure Submission Forms: http://www.qualityforum.org/QPS/0640, Accessed August 29, 2017 Donat DC. An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatr Serv. 2003 Aug;54(8):1119-23 Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1.
Aspirin at arrival Percentage of emergency department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) without aspirin contraindications who received aspirin within 24 hours before ED arrival or prior to transfer. Nominated by Dana Safran, BCBSMA Priority Area Appropriateness of hospital-based care Steward CMS NQF Endorsement Removed (0286) Summary Addresses SQAC Priority Area NQF-Endorsed or in a National Set Minimum Scores Overall Score Rating    14 (Average 3.5) Strong No Alternative Recommended for inclusion Detailed Measure Evaluation Reliability and Validity Minimum Score: 2 3 are no reliability results at the measure level, but the underlying claims data used for public reporting by CMS is extensively validated and considered the gold standard. Validity testing was strong. Amenability to Targeted Improvement No Minimum Score 3 NQF removed endorsment because this measure was "topped out". However, scores voluntarily reported by MA hospitals do show some performance gap. is evidence of a correllation between improved outcomes and immediate use of aspirin, but evidence supporting aspirin use any time within the first 24 hours is less clear. Ease of Measurement Minimum 1 4 Requires chart review, but is already publicly reported by CMS. Field Implementation Minimum Score: 1 4 Already used and publicly reported by CMS on a facility References Measure Submission and Testing Form: http://www.qualityforum.org/ProjectTemplateDownload.aspx?SubmissionID=274, Accessed August 29, 2017 A Comprehensive Review of Development and Testing for National Implementation of Hospital Core Measures: Accessed August 16, 2017 NQF-endorsed Measures for Cardiovascular Conditions: 2014. Accessed September 1, 2017
Median time to ECG Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain). Nominated by Dana Safran, BCBSMA Priority Area Appropriateness of hospital-based care Steward CMS NQF Endorsement Removed (0289) Summary Addresses SQAC Priority Area NQF-Endorsed or in a National Set Minimum Scores Overall Score Rating    11 (Average 2.75) Good No Alternative Recommended for inclusion Detailed Measure Evaluation Reliability and Validity Minimum 2 2 Variation may exist in the assignment of ICD-10-CM codes; therefore, coding practices may require evaluation to ensure consistency. There may be additional variation by provider, facility, and documentation protocol for chart-abstracted data elements. Amenability to Targeted Improvement No Minimum Score 1 NQF removed endorsement in 2014 for lack of evidence indicating that knowing the door to ECG time improves outcomes, particularly given that door to balloon time for STEMI patients is already measured. This measure is more distal to the outcome of treatment for STEMI patients; as such, the Committee did not find it to be necessary to endorse this measure, and consequently devote resources to calculating this measure, when the outcome measure is already available and in use. Ease of Measurement Minimum 1 4 Requires chart review, but is already publicly reported by CMS. Implementation Minimum Score: 1 4 Already used and publicly reported by CMS on a facility level. References Measure Submission Forms: http://www.qualityforum.org/ProjectTemplateDownload.aspx?SubmissionID=277, Accessed September 1, 2017 NQF-endorsed Measures for Cardiovascular Conditions: 2014. Accessed September 1, 2017