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Hospital Inpatient Quality Reporting

3-Item Care Transition Measure (CTM-3)

  • The CTM-3 is a hospital level measure of performance that reports the average patient reported quality of preparation for self-care response among adult patients discharged from general acute care hospitals within the past 30 days.

    CBE ID
    0228

ACEI or ARB for left ventricular systolic dysfunction- Acute Myocardial Infarction (AMI) Patients

  • Percentage of acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

    CBE ID
    0137

Death Rate among Surgical Inpatients with Serious Treatable Complications (PSI 04)

  • In-hospital deaths per 1,000 surgical discharges, among patients ages 18 through 89 years or obstetric patients, with serious treatable complications (shock/cardiac arrest, sepsis, pneumonia, deep vein thrombosis/ pulmonary embolism or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility. A risk-adjusted rate is available. The risk-adjusted rate of PSI 04 relies on stratum-specific risk models.

    CBE ID
    0351

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey

  • HCAHPS (NQF #0166) is a 29-item survey instrument that produces 10 publicly reported measures:

    6 multi-item measures (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, discharge information and care transition); and

    4 single-item measures (cleanliness of the hospital environment, quietness of the hospital environment, overall rating of the hospital, and recommendation of hospital).

    CBE ID
    0166

Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following acute myocardial infarction (AMI) hospitalization

  • The measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal diagnosis of AMI. Mortality is defined as death for any cause within 30 days after the date of admission for the index admission. CMS annually reports the measure for patients who are 65 years or older and are either Medicare fee-for-service (FFS) beneficiaries and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.

    CBE ID
    0230

Hospital 30-Day, all-cause, risk-standardized mortality rate (RSMR) following chronic obstructive pulmonary disease (COPD) hospitalization

  • The measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with either a principal discharge diagnosis of COPD or a principal discharge diagnosis of respiratory failure with a secondary discharge diagnosis of acute exacerbation of COPD.

    CBE ID
    1893