Skip to main content

Hospital Harm Pressure Injury

CBE ID
3498e
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2027
E&M Cycle Comments

Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Fall 2022 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Fall 2022 “Intent to Submit.” Battelle took over the E&M work for the Fall 2022 cycle after developers and/or stewards submitted their full measure information to NQF, which for CBE #3498e, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2024-02/3498e.zip

Battelle took over the E&M work beginning with the public comment period to close the E&M committees for the post-comment meeting, convening the CSAC to render a final endorsement decision, and executing the appeals period.

 

1.3 Measure Description
This electronic clinical quality measure (eCQM) assesses the proportion of inpatient hospitalizations for patients ages 18 years and older at the start of the encounter who suffer the harm of developing a new stage 2, stage 3, stage 4, deep tissue, or unstageable pressure injury.
        • 1.5 Measure Type
        • 1.14 Numerator

          Inpatient hospitalizations for patients with a new deep tissue pressure injury (DTI) or stage 2, 3, 4, or unstageable pressure injury, as evidenced by any of the following: •A diagnosis of DTI with the DTI not present on admission; •A diagnosis of stage 2, 3, 4 or unstageable pressure injury with the pressure injury diagnosis not present on admission; •A DTI found on exam greater than 72 hours after the start of the encounter; or •A stage 2, 3, 4 or unstageable pressure injury found on exam greater than 24 hours after the start of the encounter.

        • 1.15 Denominator

          Inpatient hospitalizations where the patient is 18 years of age or older at the start of the encounter.

        • OLD 1.12 MAT output not attached
          Attached
          1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Endorsed Patient Safety Fall 2022
          Initial Endorsement
          Last Updated
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Measure Developer Secondary Point Of Contact

          United States

              • Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off