Value Based Payment Quality Improvement Program (VBP QIP)

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NYS Means for DY4 AIT Measurement

              New–2016 New–2016  
Measure Name Data Steward Focus Area/Domain Measure Definitions Units Data Source Time Period Rate, Mean (15 or More Disch) Rate, Mean (30 or More Disch)  
Acute MI Mortality (IQI #15) AHRQ Mortality In–hospital deaths per 1,000 hospital discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital. Rate per 1,000 Discharges NYSDOH (SPARCS) 2016 93.0202 80.0807
Stroke Mortality (IQI #17) AHRQ Mortality In–hospital deaths per 1,000 hospital discharges with acute stroke as a principal diagnosis for patients ages 18 years and older. Includes metrics for discharges grouped by type of stroke. Excludes obstetric discharges and transfers to another hospital. Rate per 1,000 Discharges NYSDOH (SPARCS) 2016 81.8370 82.7880
Pneumonia Mortality (IQI #20) AHRQ Mortality In–hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients 18 years and older. Rate per 1,000 Discharges NYSDOH (SPARCS) 2016 33.1170 32.9086
CAUTI Rate per 10,000 Patient Days (Population Rate) NHSN Hospital Acquired Conditions Catheter–associated urinary tract infections (CAUTI) CAUTI Rate per 10,000 Patient Days NYSPFP 2016 2.0058 2.0058
CAUTI Rate per 1,000 Device Days NHSN Hospital Acquired Conditions Catheter–associated urinary tract infections (CAUTI) CAUTI Rate per 1,000 Device Days CMS– Hospital Compare 07/01/16 – 06/30/17 1.0089 1.0158
CLABSI Rate per 10,000 Patient Days (Population Rate) NHSN Hospital Acquired Conditions Central line–associated bloodstream infections (CLABSI) CLABSI Rate per 10,000 Patient Days or 1,000 Device Days NYSPFP 2016 1.4485 1.4485
CLABSI Rate per 1,000 Device Days NHSN Hospital Acquired Conditions Central line–associated bloodstream infections (CLABSI) CLABSI Rate per 10,000 Patient Days or 1,000 Device Days CMS – Hospital Compare 07/01/16 – 06/30/17 0.8862 0.8862
CDI Healthcare Facility – Onset Incidence Rate per 10,000 Patient Days NHSN Hospital Acquired Conditions Clostridium difficile (C diff) Laboratory–identified Events CDI Rate per 10,000 Patient Days CMS 07/01/16 – 06/30/17 4.8984 4.9633
Falls with Injury NDNQI Hospital Acquired Conditions Acute Patient Fall Rate Falls per 1,000 Patient Days NYSPFP 2015 0.5202 0.5202
3–Hour Sepsis Bundle NYSDOH Hospital Acquired Conditions The percentage of adult patients with sepsis who received all the recommended early treatments in the 3–hour early management bundle within three (3) hours Percent Compliance NYSDOH 2017 66.6799 66.0515
Pressure Ulcer Rate, Stage 2 NDNQI Hospital Acquired Conditions Prevalence rate of facility–acquired pressure ulcers of Stage 2 or higher per 100 patients Ulcers per 100 patients NYSPFP 2015 1.8040 1.8040
Episiotomy Rate Pediatric Measureme nt Center of Excellence Maternity Patients who underwent an episiotomy Per 100 Vaginal Deliveries NYSDOH 2016 13.2761 14.9389
Primary C–Section (IQI #33) AHRQ Maternity First–time 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). Rate per 1,000 Deliveries NYSDOH (SPARCS) 2016 183.0921 184.1759
Avoidable ED Use 3M Utilization Potentially Avoidable ED Use Rate per 100 Discharges NYSDOH (SPARCS) 2016 67.9838 68.0106
Avoidable Admissions 3M Utilization Potentially Avoidable Admissions Rate per 100 Discharges NYSDOH (SPARCS) 2016 19.8736 19.5173
Fibrinolytic Therapy Received with 30 minutes of ED Arrival (OP– 2) CMS Timely and Effective Care Outpatients with Chest Pain or Possible Heart Attack Who Got Drugs to Break Up Blood Clots Within 30 Minutes of Arrival (OP–2) Percent Compliance CMS 07/01/16 – 06/30/17 51.5714 N/A
Median Time to Transfer to Another Facility for Acute Coronary Intervention (OP– 3b) CMS Timely and Effective Care Average (median) number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital Minutes CMS 07/01/16 – 06/30/17 76.6429 N/A
Median Time to ECG (OP–5) CMS Timely and Effective Care Median number of minutes before outpatients with chest pain or possible heart attack got an ECG Minutes CMS 07/01/16 – 06/30/17 10.2018 N/A
EDTC Emergency Department Transfer Communication (All or None) NQF/Stratis Health Transitions of Care Patients who are transferred from an ED to another healthcare facility have all necessary communication with the receiving facility within 60 minutes of discharge Rate per 100 transfers Stroudwater 10/01/17 – 06/30/18 The National Benchmark for All EDTC is 83% N/A