Manual: National Hospital Inpatient Quality Measures

Last Updated: Version 4.2a Using the Specifications Manual for National Hospital Inpatient Quality Measures The Specifications Manual for National Hospital Inpatient Quality Measures is periodically updated for a specific data collection time period (i.e., based on hospital discharge dates) with a Version number and Effective Discharges date (e.g., Version 2.3, Effective 10/01/2007 Discharges)associated with each applicable manual. Over time, it may be necessary to present more than one version of a specific data collection time period due to corrections or clarifications based on ongoing alignment discussion between the Centers for Medicare & Medicaid Services and the Joint Commission. When more than one version of the manual is posted for a specific discharge period, an alpha characteris added following the version number to identify there were corrections or clarifications made to the previous release and this would identify the most up-todate information. This portion of The Specifications Manual provides a brief overview of the information contained within each section of the manual. It is intended for use as a quick reference to assist in the implementation of the hospitalnational quality measures. The sections of this manual are interrelated and are most useful when considered together. For each version of the manual and any addenda, it is necessary to review the Release Notes document for a detailed description of the changes that were made to The Specifications Manual. Information that is removed from documents is only contained in the Release Notes.Strikethroughs are difficult to read and are not allowed because of the requirements for accommodation for people with disabilities. Information that is added or revised within documents is contained within the Release Notes. The initial selection of medical records, intended for data abstraction of the National Hospital Quality Inpatient Measures, must meet the following criteria: • All units/areas of thehospital licensed under the hospitals acute CMS Certification Number (CCN). The acute CCN is identified by a 3rd digit of “0” for IPPS hospitals and a 3rd & 4th digit of “13” for Critical Access Hospitals. • All inpatient episodes of care billed under the hospitals acute CCN • All payor sources For measure set specific Initial Patient Populations, refer to Section 2 (“Measurement Information”) andSection 4 (“Population and Sampling Specifications”) of this manual. Section 1 - Data Dictionary The Data Dictionary describes the patient-level data elements required to capture and calculate individual measurements. It specifies those data elements that must be collected for each patient that falls into any of the selected Initial Patient Populations and those data elements needed for aspecific measure set.

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13)

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Section 2 - Measurement Information The measure information section is divided by measure sets. At the beginning of each set is a listing of the measures comprising the set, including the set measure identification number (alphanumeric number toidentify a measure within a set) and the measure short name. For example, in the Heart Failure (HF) measure set, the measure that addresses HF patients receiving discharge instructions is listed as: HF-1 and measure short name: Discharge Instructions. This is followed by a data element list for the measure set, including the general data elements, algorithm output data elements, and the specificmeasure set data elements. Next is a document that describes the Initial Patient Population and the sample size requirements for each measure set. Also included are subsections for each specific measure. These contain a Measure Information Form (MIF) and the Performance Measure Algorithm. The algorithms and data elements needed to calculate each of the national quality inpatient measures are...