Verify MICare

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

 NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

Cesarean Section Rate, Uncomplicated (IQI 21)

Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Measure type

Outcome

Numerator

Number of uncomplicated cesarean deliveries. Cesarean deliveries are identified by either DRG or MS-DRG codes for Cesarean delivery; or any-listed ICD-10-PCS procedure codes for Cesarean delivery without any-listed ICD-10-PCS procedure codes for hysterotomy.

Denominator

All deliveries, identified in ICD-10 by outcome of delivery diagnosis codes.

Exclusions

-        Any-listed ICD-10-CM diagnosis codes for abnormal presentation, preterm, fetal death, or multiple gestation

-        Missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

-        Hospitals with less than 25 deliveries during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from AHRQ IQI 21

Data source (s)

  Michigan Inpatient Database (MIDB)

Automatic transfer from

  MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

  Target

Less than or equal to Michigan state average

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

 NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Cesarean Section Rate, Uncomplicated (IQI 21)

Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Measure type

Outcome

Numerator

Number of uncomplicated cesarean deliveries. Cesarean deliveries are identified by either DRG or MS-DRG codes for Cesarean delivery; or any-listed ICD-10-PCS procedure codes for Cesarean delivery without any-listed ICD-10-PCS procedure codes for hysterotomy.

Denominator

All deliveries, identified in ICD-10 by outcome of delivery diagnosis codes.

Exclusions

-        Any-listed ICD-10-CM diagnosis codes for abnormal presentation, preterm, fetal death, or multiple gestation

-        Missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

-        Hospitals with less than 25 deliveries during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from AHRQ IQI 21

Data source (s)

  Michigan Inpatient Database (MIDB)

Automatic transfer from

  MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

  Target

Less than or equal to Michigan state average

MRSASIR: NHSN Reporting Facilities ONLY

Methicillin-Resistant Staphylococcus Aureus (MRSA) Standardized Infection Ratio (SIR)

·       All: ICUs + Other Inpatient Units

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

 - Predicted infection count less than one

 - No data reported during baseline period

 - Level II/III & Level III NICU locations

SIR calculation

Specifications/definitions

Sources/Recommendations

  Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

 NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

Cesarean Section Rate, Uncomplicated (IQI 21)

Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Measure type

Outcome

Numerator

Number of uncomplicated cesarean deliveries. Cesarean deliveries are identified by either DRG or MS-DRG codes for Cesarean delivery; or any-listed ICD-10-PCS procedure codes for Cesarean delivery without any-listed ICD-10-PCS procedure codes for hysterotomy.

Denominator

All deliveries, identified in ICD-10 by outcome of delivery diagnosis codes.

Exclusions

-        Any-listed ICD-10-CM diagnosis codes for abnormal presentation, preterm, fetal death, or multiple gestation

-        Missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

-        Hospitals with less than 25 deliveries during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from AHRQ IQI 21

Data source (s)

  Michigan Inpatient Database (MIDB)

Automatic transfer from

  MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

  Target

Less than or equal to Michigan state average

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

 NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

Cesarean Section Rate, Uncomplicated (IQI 21)

Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Measure type

Outcome

Numerator

Number of uncomplicated cesarean deliveries. Cesarean deliveries are identified by either DRG or MS-DRG codes for Cesarean delivery; or any-listed ICD-10-PCS procedure codes for Cesarean delivery without any-listed ICD-10-PCS procedure codes for hysterotomy.

Denominator

All deliveries, identified in ICD-10 by outcome of delivery diagnosis codes.

Exclusions

-        Any-listed ICD-10-CM diagnosis codes for abnormal presentation, preterm, fetal death, or multiple gestation

-        Missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

-        Hospitals with less than 25 deliveries during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from AHRQ IQI 21

Data source (s)

  Michigan Inpatient Database (MIDB)

Automatic transfer from

  MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

  Target

Less than or equal to Michigan state average

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN

Data source (s)

 NHSN (all inpatient locations)

Automatic transfer from

 NHSN- for hospitals conferring rights to MHA Keystone Center

Data collection start date

2 year rolling comparison

NHSN Baseline evaluation period

Calendar year 2015

Target

Less than or equal to 1

Notes

This measure is only collected for hospitals submitting data to

NHSN and conferring rights to MHA.

Cesarean Section Rate, Uncomplicated (IQI 21)

Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Measure type

Outcome

Numerator

Number of uncomplicated cesarean deliveries. Cesarean deliveries are identified by either DRG or MS-DRG codes for Cesarean delivery; or any-listed ICD-10-PCS procedure codes for Cesarean delivery without any-listed ICD-10-PCS procedure codes for hysterotomy.

Denominator

All deliveries, identified in ICD-10 by outcome of delivery diagnosis codes.

Exclusions

-        Any-listed ICD-10-CM diagnosis codes for abnormal presentation, preterm, fetal death, or multiple gestation

-        Missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

-        Hospitals with less than 25 deliveries during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from AHRQ IQI 21

Data source (s)

  Michigan Inpatient Database (MIDB)

Automatic transfer from

  MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

  Target

Less than or equal to Michigan state average

Hospital Inpatient Mortality

Patients with a discharge status of expired.

Measure type

Outcome

Numerator

Number of observed patients with a discharge status of expired

Denominator

Number of predicted patients with a discharge status of expired

Exclusions

 - Hospice patients

 - Stillborn

 - Transfer patients

 - Hospitals with less than 30 inpatient admissions during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

Available from Data Koala, Severity Adjusted Mortality Report

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Less than or equal to 1

Notes

APR-DRGs are grouped on to each discharge using a grouper during MHA’s production process. This grouper comes from 3M and is proprietary. The grouper cannot be ‘exported’ as the grouping goes on behind the scenes in a ‘black box’. Multiple MS-DRGs can make up one APR-DRG.

APR DRGs are designed to measure:

• Severity of Illness:the extent of physiologic decomposition or organ system loss of function
• Risk of Mortality: the likelihood of in hospital death for a patient
• Resource Intensity:the relative volume and types of diagnostic, therapeutic and bed services used

Other APR DRG modifiers:

• Age
• Combination of non-Operating Room procedures and primary diagnoses
• Combinations of categories of secondary diagnoses

Readmission:

Readmission within 30 Days

·       Readmissions to any facility

·       Adjusted for severity

Measure type

Outcome

Numerator

Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator

Number of at-risk inpatient discharges

Exclusions

Listed within the below reference document

Rate calculation

Specifications/definitions

Sources/Recommendations

Facilities should follow the CMS HWR 5.0 definition of an unplanned readmission – Yale

Data source (s)

Michigan Inpatient Database (MIDB)

Data Extraction

Re>>admetrix

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Note: The CMS definition only includes Medicare FFS patients but we    will include all patients > 17 years of age, regardless of payer.

Retained Surgical Item

Retained surgical item or unretrieved device fragment cases among surgical and medical patients per 1,000 surgical discharges.

Measure type

Outcome

Numerator

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients.

Denominator

Number of surgical or medical discharges for patients 18 years and older or MDC 14, as defined by specific MS-DRG codes.

Exclusions

 - Cases with principal diagnosis of retained surgical item or unretrieved device fragment

 - Cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

- Hospitals with less than 25 surgical or medical discharges during a rolling 12 months

Rate calculation

Specifications/definitions

Sources/Recommendations

  Referenced AHRQ:  PSI-05

Medical Discharge MS-DRGs:  PSI Appendix C

Surgical Discharge MS-DRGs: PSI Appendix E

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

2 year rolling comparison

Target

Zero

Note

Data definition references PSI-05, but we add a denominator to create a rate.

PE/DVT: AHRQ PSI 12

Number of surgical patients that develop a Perioperative Pulmonary Embolism or Deep Vein Thrombosis per 1,000 surgical discharges.

Measure type

Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field

Denominator

Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure

Exclusions

-   Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis

-   Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission

-   Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure

-   Obstetric discharges

Rate calculation

Specifications/definitions

Sources/Recommendations

  Available from AHRQ:  PSI-12

Surgical Discharge Specifications:  PSI Appendix E

Operating Room Procedure Codes: PSI Appendix A

Data source(s)

 Michigan Inpatient Database (MIDB)

Automatic transfer from

 MIDB for hospitals reporting to MHA Data Services

Data collection start date

Q4 2015

Target

Less than the Michigan state average

Early Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at  37 and < 39 weeks of gestation completed.

Measure type

Outcome

Numerator

Patients with elective deliveries for one or more of the following:

- Medical induction of labor while not in Labor prior to the procedure

- Cesarean birth:

            - not in Labor

- no history of a Prior Uterine Surgery

Denominator

 Patients delivering newborns with  37 and < 39 weeks of gestation    completed

Exclusions

- ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation

- Less than 8 years of age

- Greater than or equal to 65 years of age

- Length of Stay >120 days

- Gestational Age < 37 or  39 weeks or UTD

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from Joint Commission, PC-01

Data source (s)

 CMS Hospital Compare

Data Extraction

 Data.Medicare.gov – Timely and Effective Care – Hospital Report

Data collection start date

2 year rolling comparison

Target

Less than or equal to Michigan state average

Notes

Sampled data reported as aggregate rate generated from count data reported as proportion.

C. diff SIR: NHSN Reporting Facilities ONLY

 Hospital Onset (HO) C. difficile (CDI) Standardized Infection Ratio (SIR)

Measure type

Outcome

Numerator

Number of observed infections

Denominator

Number of predicted infections

Exclusions

-   Predicted infection count less than one

-   No data reported during baseline period

Rate calculation

Specifications/definitions

Sources/Recommendations

 Available from CDC NHSN