Value Based Payment Quality Improvement Program (VBP QIP)

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NYS Means for DY5 AIT Measurement

Measure Name Data Steward Focus Area/Domain Measure Definitions Units Data Source Time Period
(2017)		 Rate, Mean
(15 or More Disch)
2017		 Rate, Mean
(30 or More Disch)
2017		  
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) 2017 79.9398 70.0169
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) 2017 85.6956 77.5641
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) 2017 31.0542 31.6032
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 2017 1.6519 1.6519
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 2017 0.9734 0.9734
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 2017 1.2815 1.2815
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 2017 0.9632 0.9632
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 2017 4.7794 4.7794
Falls with Injury NDNQI Hospital Acquired Conditions Acute Patient Fall Rate Falls per 1,000 Patient Days NYSPFP 2017 0.5298 0.5298
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 2018 70.7259 70.7010
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 2017 1.5000 1.5000
Episiotomy Rate Pediatric Measurement Center of Excellence Maternity Patients who underwent an episiotomy Per 100 Vaginal Deliveries NYSDOH 2017 11.6620 12.7205
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) 2017 186.0160 186.0160
Avoidable ED Use 3M Utilization Potentially Avoidable ED Use Rate per 100 Discharges NYSDOH (SPARCS) 2017 59.2471 59.5857
Avoidable Admissions 3M Utilization Potentially Avoidable Admissions Rate per 100 Discharges NYSDOH (SPARCS) 2017 18.4083 17.9728
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 10/1/2017–
9/30/2018		 64.8889 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 10/1/2017–
9/30/2018		 72.8462 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 10/1/2017–
9/30/2018		 10.2222 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     N/A