“Sixty percent of [my team’s] work time is now freed up from not having to do abstraction to making improvements. And that is vital at a time when resources are at a premium.”
— Mary Mang, director of quality and outcomes management at Carson Tahoe Regional Healthcare
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List of core measure abstraction solutions:
ACHF: Advanced Certification in Heart Failure Measure
- ACHF-1 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge
- ACHF-2 Post-Discharge Appointment for Heart Failure Patients
- ACHF-3 Care Transition Record Transmitted
- ACHF-4 Discussion of Advance Directives/Advance Care Planning
- ACHF-5 Advance Directive Executed
- ACHF-6 Post-Discharge Evaluation for Heart Failure Patients
AMI: Acute Myocardial Infarction Measures
- AMI-1 Aspirin at Arrival
- AMI-2 Aspirin Prescribed at Discharge
- AMI-3 ACEI or ARB for LVSD
- AMI-4 Adult Smoking Cessation Advice/Counseling
- AMI-5 Beta Blocker Prescribed at Discharge
- AMI-7 Median Time to Fibrinolysis
- AMI-7a Fibrinolytic Therapy
- AMI-8 Median Time to Primary PCI
- AMI-8a Primary PCI Received
- AMI-10 Statin Prescribed at Discharge
CAC: Children’s Asthma Care Measures
- CAC-1 Use of Relievers for Inpatient Asthma
- CAC-2 Use of Systemic Corticosteroids for Inpatient Asthma
- CAC-3 Home Management Plan of Care Given to Patient/Caregiver
CCM: Care Coordination Measures
- CCM-1: Reconciled Medication List Received by Patient at Discharge
- CCM-2: Transition Record with Data Received by Patient at Discharge
- CCM-3: Timely Transmission of Transition Record
Emergency Department (ED) Throughput
- ED-1 Median Time—From ED Arrival to ED Departure for Admitted ED Patients
- ED-2 Median Time—Admit Decision Time to ED Departure for Admitted Patients
HBIPS: Hospital-Based Inpatient Psychiatric Service Measures
- HBIPS-1 Admission screening for violence risk, substance use, and psychological trauma history
- HBIPS-2 Hours of physical restraint use
- HBIPS-3 Hours of seclusion use
- HBIPS-4 Patients discharged on multiple antipsychotic medications
- HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification
- HBIPS-6 Post discharge continuing care plan created
- HBIPS-7 Post discharge continuing care plan transmitted to next level of care provider upon discharge
HF: Heart Failure Measures
- HF-1 Discharge Instructions
- HF-2 Evaluation of LVS Function
- HF-3 ACEI or ARB for LVSD
HOP: Hospital Outpatient Measures
- HOP AMI: Acute Myocardial Infarction
- OP-1 Median Time to Fibrinolysis
- OP-2 Fibrinolytic Therapy Received
- OP-3 Median Time to Transfer
- OP-4 Aspirin at Arrival
- OP-5 Median Time to ECG
- HOP CP: Chest Pain Measures
- OP-4 Aspirin at Arrival
- OP-5 Median Time to ECG
- HOP ED Throughput: Emergency Department Throughput
- OP-18 Median Time From Arrival to Departure
- OP-20 Door to Diagnostic Evaluation
- OP-22 ED-Median Time to Pain Management
- HOP PM: Pain Management
- OP-21 ED-Median Time to Pain Management for Long Bone Fracture
- HOP SCIP: Surgical Care Improvement Project
- OP-6 Timing of Antibiotic Prophylaxis
- OP-7 Antibiotic Selection
- HOP STROKE: Stroke
- OP-23 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 Minutes of ED Arrival
- HOP Web-based Measures
- OP-29 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
- OP-30 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps—Avoidance of Inappropriate Use
- OP-33 External Beam Radiotherapy for Bone Metastases
IMM: Immunization Measures
- IMM-1 Pneumococcal Immunization (PPV23)
- IMM-2 Influenza Immunization
Inpatient ED: Emergency Department (ED) Measures
- ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients
- ED-2 Admit Decision Time to ED Departure Time for Admitted Patients
MassHealth AHQM: Massachusetts Health Acute Hospital Quality Measures
Maternity
- MAT-3 Elective Delivery < 39-Weeks Gestation
- MAT-4 Cesarean Birth
- MAT-5 DVT Prophylaxis for Cesarean Delivery
Newborn
- NEWB-1 Exclusive Breast Milk Feeding
- NEWB-2 Newborn Bilirubin Screening
PC: Perinatal Care Measures
- PC-01 Elective Delivery
- PC-02 Cesarean Birth
- PC-03 Antenatal Steroids
- PC-04 Healthcare-Associated Bloodstream Infections in Newborns
- PC-05 Exclusive Breast Milk Feeding
PN: Pneumonia Measures
- PN-3a Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
- PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received
- PN-6 Initial Antibiotic Selection for Community-Acquired Pneumonia in Immunocompetent
Patients
SCIP: Surgical Care Improvement Project Measures
- SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
- SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
- SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
- SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 A.M. Postoperative Blood Glucose
- SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal
- SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery Being Day Zero
- SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management
- SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period
- SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
- SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
SEP: Sepsis Bundle Project Measures
- SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock
STK: Stroke
- STK-1 Venous Thromboembolism (VTE) Prophylaxis
- STK-2 Discharged on Antithrombotic Therapy
- STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
- STK-4 Thrombolytic Therapy
- STK-5 Antithrombotic Therapy By End of Hospital Day 2
- STK-6 Discharged on Statin Medication
- STK-8 Stroke Education
- STK-10 Assessed for Rehabilitation
SUB: Substance Abuse Measures
- SUB-1 Alcohol Use Screening
- SUB-2 Alcohol Use Brief Intervention Provided or Offered
- SUB-2a Alcohol Use Brief Intervention Treatment
- SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge
- SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge
TOB: Tobacco Treatment Measures
- TOB-1 Tobacco Use Screening
- TOB-2 Tobacco Use Treatment Provided or Offered
- TOB-2a Tobacco Use Treatment
- TOB-3 Tobacco Use Treatment Provided or Offered at Discharge
- TOB-3a Tobacco Use Treatment at Discharge
VTE: Venous Thromboembolism Measures
- VTE-1 Venous Thromboembolism Prophylaxis
- VTE-2 Intensive Care Venous Thromboembolism Prophylaxis
- VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
- VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin With Dosages/Platelet Count Monitoring by Protocol
- VTE-5 Venous Thromboembolism Discharge Instructions
- VTE-6 Incidence of Potentially Preventable Venous Thromboembolism