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Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI)

Endorsement Status
1.1 New or Maintenance
Is Under Review
Next Planned Maintenance Review
Spring 2028
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 Spring 2023 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 Spring 2023 “Intent to Submit.” Battelle took over the E&M work for the Spring 2023 cycle when developers and/or stewards submitted their full measure information, which for CBE #3728, the most recent measure specifications can be found here:

To close out this E&M cycle, Battelle published the Spring 2023 measures for pre-evaluation public commenting, convened the E&M standing committees for their measure evaluation meetings, launched the Spring 2023 post-comment period, convened the E&M committees for the post-comment meeting, convened the CSAC to render a final endorsement decision, and executed the appeals period.


1.3 Measure Description

SNF HAI is a one-year outcome measure that estimates the risk-standardized rate of healthcare-associated infections (HAIs) that are acquired during SNF care and result in hospitalization.

        • 1.14 Numerator

          The measure numerator is the number of stays with an HAI acquired during SNF care and resulting in an inpatient hospitalization. The hospitalization must occur during the period beginning on day four after SNF admission and within three days of SNF discharge.

        • 1.15 Denominator

          The study population includes Medicare Part A fee-for-service (FFS) SNF stays that were admitted during the measure time period (one year) and that meet the inclusion criteria during the measurement period.

        • Exclusions

          SNF stays are excluded from the denominator if they meet one or more of the following criteria: (i) residents who are less than 18 years of age at the time of admission; (ii) the SNF length of stay was shorter than four days; (iii) residents who were not continuously enrolled in Part A FFS Medicare during the SNF stay, 12 months prior to the measure period, and three days after the end of the SNF stay; (iv) residents who did not have a Part A short-term acute care hospital stay within 30 days prior to the SNF admission date (the short-term stay must have positive payment and positive length of stay); (v) residents who were transferred to a federal hospital from the SNF as determined by the discharge status code on the SNF claim, (vi) residents who received care from a provider located outside of the United States, Puerto Rico, or a United States territory as determined from the first two characters of the SNF CCN; (vii) SNF stays in which data were missing on any variable used in the measure construction or risk adjustment, (viii) stays where Medicare did not pay for the stay resulting in a non-positive payment on the SNF claim, and (xi) swing bed stays in critical access hospitals.

        • OLD 1.12 MAT output not attached
        • Most Recent Endorsement Activity
          Patient Safety Spring 2023
          Initial Endorsement
              • Risk Adjustment
                Risk adjustment approach
                Risk adjustment approach
                Conceptual model for risk adjustment
                Conceptual model for risk adjustment