Final Draft HRC

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COLORADO HOSPITALREPORT CARD________________________________Implementation Plan of House Bill 06-1278

Prepared byColorado Hospital AssociationHospital Report Card Implementation CommitteeMay 15, 2007


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TABLE OF CONTENTSCOLORADO HOSPITAL REPORT CARDI. Preamble.............................................................................................................................3 II. Purpose of the Plan ..........................................................................................................3 III. Structure ............................................................................................................................ 4A. Colorado Department of Public Health and Environment (CDPHE)............................ 4B. Colorado Hospital Association (CHA) ..............................................................................5C. Hospital Report Card Implementation Committee .........................................................5D. Performance & Quality Coalition .....................................................................................6E. Communications Work Group.........................................................................................6F. Focus Groups and Consumers ......................................................................................... 6IV. Process for Selection of Measures ................................................................................ 7A. Process for Submission of New Measures ...................................................................... 8B. Process for Inclusion of New Measures...........................................................................9V. Process for Data Analysis ...............................................................................................9 VI. Process for Annual Release of Data ..............................................................................9 VII. Phase I (2007) .................................................................................................................10 A. Implementation Timelines .............................................................................................. 10B. Phase I Measures............................................................................................................... 11VIII. Phase II..............................................................................................................................13 A. Balanced Scorecard Approach ..........................................................................................13B. Efficiency of Care.............................................................................................................. 14C.

Hospital-Acquired Infection Measures............................................................................15

D. Pediatric Measures ............................................................................................................15IX. Annual Evaluation of Effectiveness .............................................................................16 X. Barriers to Implementation ..........................................................................................16 XI. Continuous Efforts to Improve Care ........................................................................... 17XII. Appendix .......................................................................................................................... 18A. Measure Definitions (reported by county) ...................................................................... 18B. Measure Definitions (reported by individual hospitals) ............................................... 24C. Hospital Report Card Implementation Committee (current as of 5.15.07)....................31D. Performance & Quality Coalition (current as of 5.15.07)................................................33E. List of Common Acronyms............................................................................................. 34F. Relevant Links for Inclusion on Report Card Website...................................................35


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I. PreambleThe Colorado Hospital Report Card has the primary purpose of ensuring that

statewide hospital data and clinical outcomes are made available to the general

public in a clear and usable manner. The public disclosure of this data will be

made available on an internet website in a manner that not only allows

consumers to conduct an interactive search to compare information from specific

hospitals, but will also provide appropriate guidance on how to use and

understand the data. The Colorado Hospital Report Card will utilize

standardized quality and clinical outcome measures that are endorsed by national

organizations, with established standards to measure the performance of

healthcare providers and hospitals.

II. Purpose of the PlanA key objective of the Colorado Hospital Report Card is to uphold a statewide

commitment to hospital quality improvement, accountability and transparency.

The purpose of this implementation plan is to provide a framework for the

execution of House Bill 06-1278, created in a collaborative process that includes

the participation of the Colorado Department of Public Health and Environment,

Colorado Hospitals, consumers and other stakeholder organizations. This

framework is inclusive of key elements such as a participation structure, flow of

responsibility, distinct processes for selection of measures, data analysis and data

release, proposed content for the two phases defined in the implementation plan

and a plan for annual review of effectiveness. Although the long term goal of the

report card is for it to be inclusive of measures that are applicable to alldemographics and diverse communities, there are some measures that may not

be appropriate to use for direct comparison of some hospitals given the nature of

the patient population, size of hospital or frequency and number of procedures.

Appropriate consideration for applicable measures will be given to all types of


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hospitals throughout the state to ensure a process of accountability for hospital

practices and development of quality improvement initiatives for best delivery of

healthcare in Colorado.

III. StructureThe organizational chart and accompanying description of each party defines the

flow of responsibility for the implementation plan of the Colorado Hospital

Report Card.

A. Colorado Department of Public Health and Environment (CDPHE)The Colorado Department of Public Health and Environment (CDPHE) has a

key responsibility to monitor the development and implementation of the

Colorado Hospital Report Card. A CDPHE employee is represented on both

the Performance & Quality Coalition and Hospital Report Card

Implementation Committee. CDPHE and the Colorado Hospital Association

will collaborate on all major processes of the Colorado Hospital Report Card

Colorado Department of Public Health andEnvironmentColorado HospitalAssociation

Performance & QualityCoalition Hospital Report CardImplementation CommitteeCommunications WorkGroup Focus Groups andConsumers


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including approving a framework, executing the implementation plan,

monitoring progress and the development of future work.

B. Colorado Hospital Association (CHA)The Colorado Hospital Association (CHA) has the responsibility of ensuring

that the final plan submitted to CDPHE on or before April 15, 2007 meets all

of the required elements as stipulated by House Bill 06-1278. CHA also is

responsible for ensuring that the final plan is implemented as proposed by

this document.

C. Hospital Report Card Implementation CommitteeThe Hospital Report Card Implementation Committee is responsible for

identifying and recommending the primary elements of the Colorado Hospital

Report Card, as well as evaluating the overall effectiveness of the report card

and implementation plan on an ongoing basis. The consideration of

measures for the report card will rely on a process using a defined set of

criteria outlined in section I.V. to select measures for inclusion in the

implementation plan as well as for future iterations of the Colorado Hospital

Report Card. The Hospital Report Card Implementation Committee is also

responsible for ensuring that the selection of measures, data analysis and data

release meets the defined processes as outlined in this implementation plan.

The Hospital Report Card Implementation Committee is composed of a broad

membership from the healthcare community including representatives of

hospitals, quality improvement organizations, CDPHE, payers, purchasersand the business community (see appendix C).


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D. Performance & Quality CoalitionThe Performance & Quality Coalition is responsible for facilitating the

development and long term progress of the Colorado Hospital Report Card by

acting in an advisory capacity to the Hospital Report Card Implementation

Committee. The Performance & Quality Coalition is composed of a broad

membership from the healthcare community including representatives of

hospitals, quality improvement organizations, CDPHE, payers, purchasers

and the business community (see appendix D).

E. Communications Work GroupThe Communications Work Group is responsible for ensuring that the

Colorado Hospital Report Card is released to targeted audiences. The

Communications Work Group will facilitate the ongoing release of new data

to hospitals and consumer groups and serve as the point of contact for any

media inquiries that pertain to the Colorado Hospital Report Card. This work

group will ensure that the general public and other audiences have knowledge

of comparative hospital quality information and that this information is in a

functional format such that it is understandable and usable.

F. Focus Groups and ConsumersVarious focus groups will be organized by the CHA Communications Director

in coordination with CDPHE and the Communications Work Group to solicit

feedback on the website design and overall usability of the Colorado Hospital

Report Card. Focus groups will be surveyed prior to the first official datarelease as well as on a continued basis to evaluate the ongoing effectiveness of

the report card. Current suggested focus groups include: consumers,

hospitals, physicians, purchasers and media. Particular focus will be placed


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on surveying consumers as they are the targeted population for the utilization

of the report card.

IV. Process for Selection of MeasuresThe consideration and selection of measures for inclusion in the Colorado

Hospital Report Card will be defined by a rigorous process to ensure consistency

and continued applicability. The consideration and selection of new or modified

measures will be an ongoing process. The flow of consideration and subsequent

approval for new or modified measures is defined below:

As a general rule, only measures that have met certain criteria will be considered

for inclusion in the Colorado Hospital Report Card. This criteria has been

defined by quality improvement experts and other related professionals to ensure

that the Colorado Hospital Report Card meets the objectives and goals set forth by

the implementation plan.

Colorado Department of Public Health and EnvironmentFinal a roval authorit of new or modified measures

Colorado Hospital Association BoardEndorses measure selection for resentation to CDPHE

Performance & Quality CoalitionActs in an advisor ca acit for selection of new measures

Hospital Report Card Implementation CommitRecommends measures based on defined criteria


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The defined criteria established by the Hospital Report Card Implementation

Committee include:

The collection of data and definition of measures must be consistent andunambiguous across all Colorado hospitals.

The measures and accompanying definition must be understandable andusable to the public.

The measures must be reliable (consistent) and valid (precise, logical). The measures must have statistical significance when used for

comparison of hospitals.

The measures must be actionable by hospitals and/or medical staff. The measures must be endorsed by quality standard groups (e.g. National

Quality Forum, National Association of Childrens Hospitals and Related

Institutions).

The measures must be applicable to current public health and healthcaregoals for quality improvement.

All parties defined in the flow chart have a responsibility of ensuring that both

the selection criteria and current designated measures meet the changing

needs of consumers and are applicable to the current needs and concerns of

public health.

A. Process for Submission of New MeasuresInterested parties will have an opportunity to propose measures for possible

inclusion in the Colorado Hospital Report Card. Requests for consideration

may be submitted to the Hospital Report Card Implementation Committee

provided that they are inclusive of a brief explanation of the proposed measure

and a short justification for the purpose and need of such an inclusion. A list


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of all proposed measures will be maintained and included in an annual report

to CDPHE.

B. Process for Inclusion of New MeasuresNew measures will be considered for inclusion in the Colorado Hospital

Report Card by the Hospital Report Card Implementation Committee on an

ongoing basis. The Hospital Report Card Implementation Committee will

evaluate proposed measures based on the criteria outlined in section I.V. The

Implementation Committee will also utilize the recommendations of quality

improvement experts and other stakeholder entities. Recommendations for

new or modified measures will be shared with the Performance & Quality

Coalition for review and comment. Selected measures by the Hospital Report

Card Implementation Committee will then be presented to the CHA Board for

review and endorsement. The final approval authority of new or modified

measures rests with CDPHE.

V. Process for Data AnalysisData that specifically pertains to measures selected for inclusion in the Colorado

Hospital Report Card will be collected from all Colorado hospitals on an annual

basis. Data from the most recent three year period will be collected and analyzed

by CHA. The integrity of the data will be evaluated prior to the official release on

the public website. Statewide or other geographic trends will also be evaluated as

part of the data analysis. Valid trends that are identified will be shared with

hospitals in an effort to facilitate improvement in specific areas of healthcare.

VI. Process for Annual Release of DataThe annual release of data to the general public will be facilitated by the CHA

Communications Director and Communications Work Group. It is essential that


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the process of releasing annual data is such that it ensures that this information is

easily accessible, readily available and widely publicized. The release of annual

data to all Colorado hospitals will occur prior to the official release of data and

results to the public as stipulated by House Bill 06-1278. This data will be given

to all Colorado hospitals one month prior to the public release to provide an

opportunity for thorough review and comment from all hospitals.

VII. Phase I (2007)A. Implementation Timelines

April 15, 2007 Submit a plan to the executive director of CDPHE and report on the

status of implementation of House Bill 06-1278.

May 1, 2007 Begin the detailed development of the website. Initiate the communications plan.

May 15, 2007 Submit a final plan and report on the status of implementation to

the Governor, the President of the Senate and the Speaker of the

House of Representatives.

Provide copies of the implementation plan to all members of thegeneral assembly and made the plan available to the public on an

internet website.

June 2007 September 2007 Engage focus groups and stakeholders.

September 15, 2007 Make the Colorado Hospital Report Card available to every hospital

in the state to ensure that each hospital has the opportunity to

evaluate the data and submit comments.


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October 15, 2007 Submit the Colorado Hospital Report Card plan to the executive

director of CDPHE for approval of the public disclosure of data.

November 30, 2007 Publish the Colorado Hospital Report Card to the general public as

stipulated by House Bill 06-1278.

B. Phase I MeasuresData that will be used in the Colorado Hospital Report Card is collected and

compiled by the Colorado Hospital Association on an ongoing basis from all

acute care hospitals in Colorado. Phase I of the Hospital Report Card will be

inclusive of data from 2004, 2005 and 2006.

1. Agency for Healthcare Research and Quality (AHRQ) Risk-AdjustedMortality Rate Quality Measures

a. Condition Measures Acute Myocardial Infarction (AMI) Congestive Heart Failure (CHF) Gastrointestinal Hemorrhage (GI bleed) Hip Fracture Pneumonia Stroke

b. Procedure Measures Carotid Endarterectomy (CEA) Coronary Artery Bypass Graft (CABG) Craniotomy Hip Replacement Percutaneous Transluminal Coronary Angioplasty (PTCA)


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2. AHRQ Volume Measures Abdominal Aortic Aneurysm Repair (AAA) Carotid Endarterectomy (CEA) Coronary Artery Bypass Graft (CABG) Percutaneous Transluminal Coronary Angioplasty (PTCA)

3. AHRQ Prevention Quality Measuresa. These prevention quality measures represent hospital admission

rates (by patients county of residence) for the following ambulatory

care-sensitive conditions:

Amputations, lower extremity, diabetic patients Angina, without procedure Appendicitis, perforated Asthma, adult Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Dehydration Diabetes, long-term complications Diabetes, short-term complications Diabetes, uncontrolled Hypertension Low Birth Weight

Pneumonia Urinary Tract Infections (UTI)


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4. Other Quality Measuresa. AHRQ Patient Safety Measures

Decubitus Ulcer Rate Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)

Rate, postoperative

Sepsis Rate, postoperativeb. Hospital-Acquired Infection Measuresc. Pediatric Measures

VIII. Phase IIA. Balanced Scorecard Approach

The long term goal for the Colorado Hospital Report Card is for it to be

comprised of a comprehensive set of measures that address various aspects of

quality improvement. The Hospital Report Card Implementation Committee

has identified possible areas of focus for the next phase of the report card,

however other areas that have not yet been identified in this implementation

plan can be considered for inclusion in future iterations of the report card

provided they meet the criteria outlined in section I.V. and speak to the

balanced scorecard approach of this implementation plan.

1. Clinical Quality AHRQ Quality Measures AHRQ Prevention Measures

2. Patient Safety AHRQ Patient Safety Measures Hospital-Acquired Infection Measures (as reported by Colorado

hospitals)


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3. Patient Satisfaction U.S. Department of Health and Human Services (HHS) Hospital

Consumer Assessment of Health Providers and Systems Survey

(HCAHPS) Measures

4. Best Practices Centers for Medicare & Medicaid Services (CMS) Core Measures /

HHS Hospital Compare

IHI 100,000 Lives Campaign IHI 5 Million Lives Campaign

5. Efficiency of Care

B. Efficiency of CareAs it pertains to the Colorado Hospital Report Card, efficiency of care will be

defined as a measure of quality of care in combination with healthcare

resource use. Currently, measures that are used to evaluate efficiency rely on

proxies for measuring efficiency and costs of care such as hospital charges and

average length of stay. It has not been demonstrated that these proxies

accurately reflect resource use, especially given the consideration of various

confounders that may influence outcomes.

The Hospital Report Card Implementation Committee and CDPHE will

evaluate emerging efficiency and cost measures as they are developed. Many

organizations, including AHRQ, CHA and the Colorado Foundation for

Medical Care (CFMC), are conducting research to examine potential cost

measures including cost to charge ratios, hospital payment rates and hospital

readmission rates. Validated efficiency and cost measures will be considered

for inclusion in the Colorado Hospital Report Card as they are developed and

may be included in future iterations of the report card provided that they meet


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the defined selection criteria set forth in section I.V. and have been endorsed

by recognized quality standard groups as valid and reliable measures.

C. Hospital-Acquired Infection MeasuresHospital-acquired infection rates are important measures for inclusion on the

Colorado Hospital Report Card. Legislation was recently passed in Colorado

that mandates reporting of hospital-acquired infections to the Centers for

Disease Control and CDPHE. An infection advisory committee has been

appointed and will meet on a regular basis to determine which infection rates

will be reported for certain medical procedures. Although a separate report

will be generated by the Health Facility-Acquired Infection Advisory

Committee, it is the goal of the Colorado Hospital Report Card to have these

infection measures included in the report card and disseminated in a manner

that is meaningful to the public. Hospital-acquired infection measures will be

included in future iterations of the report card as they become available

through CDPHE.

D. Pediatric MeasuresCurrent pediatric quality measures, such as those published by AHRQ, have a

significant risk of misinforming the public since these measures are mostly

an assessment of rare events. The incidence rate of rare event measures have

the potential to be aversely biased in institutions caring for high-risk

individuals, which may result in unintentional misinformation to the general

public about health quality measures in these specific hospitals.

The Hospital Report Card Implementation Committee and CDPHE will

consider new pediatric quality measures as they are developed and validated.

Pediatric quality measures that successfully detect bias and are designed to


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appropriately adjust risk will be considered for inclusion in the Colorado

Hospital Report Card on an annual basis provided they meet the defined

criteria set forth in section I.V. and are recognized by quality standard groups

as valid and reliable measures.

IX. Annual Evaluation of EffectivenessThe Hospital Report Card Implementation Committee is responsible for the

ongoing evaluation of the Colorado Hospital Report Card. This committee will

establish a formal process for an annual review of the Colorado Hospital Report

Card and implementation plan. The annual review will largely involve evaluating

the ongoing effectiveness of the Colorado Hospital Report Card as well as the

implementation plan to ensure that the established elements adequately address

the long term goal of the report card. The assessment of the Colorado Hospital

Report Card will involve the review of quality improvement measures and

evaluation of the public website used for reporting the data. New measures will

be considered and selected for inclusion to meet the changing needs of the

consumers and current included measures will be reviewed to ensure their

ongoing applicability. The website will also be assessed annually for consumer

usability. Focus groups will be engaged on a regular basis to facilitate this process

and provide outside perspective and opinion. Lastly, potential barriers for best

implementation of the Colorado Hospital Report Card will be assessed regularly

by the Implementation Committee. Annual reports will be submitted to CDPHE.

X. Barriers to ImplementationAt the time of presentation of the implementation plan to the Governor, the

President of the Senate and the Speaker of the House of Representatives, the

Hospital Report Card Implementation Committee has not identified any barriers

that may hinder the implementation of House Bill 06-1278.


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XI. Continuous Efforts to Improve CareCDPHE and CHA are committed to the continuous improvement of healthcare

quality and patient safety improvements. CDPHE and CHA will continue to

collaborate with various outside entities to ensure that new quality improvement

efforts and best practice opportunities are reviewed on an annual basis.


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XII. AppendixA. Measure Definitions (reported by county)

1. Amputation Admission Rate, lower extremity, diabetic patients(AHRQ Prevention Quality Measure)

Description - Diabetes is a major risk factor for lower-extremityamputation, which can be caused by infection, neuropathy andmicrovascular disease.

Rate Calculation - Calculated as number of admissions for lower-extremity amputation among patients with diabetes per 100,000population.

Justification - Proper and continued treatment and glucose control mayreduce the incidence of lower-extremity amputation and lower ratesrepresent better quality care.

2. Angina Admission Rate, without procedure(AHRQ Prevention Quality Measure)

Description - Most heart attacks involve discomfort in the center of thechest that lasts for more than a few minutes or goes away and comes

back. This discomfort, known as angina, can feel like uncomfortablepressure, squeezing, fullness or pain. Both stable and unstable anginaare symptoms of potential coronary artery disease. Effectivemanagement of coronary disease reduces the occurrence of majorcardiac events such as heart attacks and may also reduce admissionrates for angina.

Rate Calculation - Calculated as number of admissions for anginawithout procedure per 100,000 population.

Justification - Proper outpatient treatment may reduce admissions forangina (without procedure) and lower rates represent better qualitycare.


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3. Appendicitis Admission Rate, perforated(AHRQ Prevention Quality Measure)

Description - Perforated appendix may occur when appropriatetreatment for acute appendicitis is delayed for a number of reasons,including problems with access to care, failure by the patient tointerpret symptoms as important, misdiagnosis and other delays inobtaining surgery.

Rate Calculation - Calculated as the number of admissions forperforated appendix as a share of all admissions for appendicitis withinan area.

Justification - Timely diagnosis and treatment may reduce theincidence of perforated appendix and lower rates represent betterquality care.

4. Asthma Admission Rate, adult(AHRQ Prevention Quality Measure)

Definition - Asthma is a disease that affects the lungs. It causesrepeated episodes of wheezing, breathlessness, chest tightness andnighttime or early morning coughing. Asthma is one of the mostcommon reasons for hospital admission and emergency room care.

Rate Calculation - Calculated as number of admissions for asthma inadults per 100,000 population.

Justification - Proper outpatient treatment may reduce the incidenceor exacerbation of asthma requiring hospitalization and lower ratesrepresent better quality care.

5. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate(AHRQ Prevention Quality Measure)

Definition - Chronic obstructive pulmonary disease (COPD) comprisesthree primary diseases that cause respiratory dysfunction - asthma,emphysema, and chronic bronchitis - each with distinct etiologies,treatments and outcomes. This measure examines emphysema andbronchitis only; asthma is discussed separately.


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Rate Calculation - Calculated as number of admissions for COPD per100,000 population.

Justification - Proper outpatient treatment may reduce admissions forCOPD and lower rates represent better quality care.

6. Congestive Heart Failure (CHF) Admission Rate(AHRQ Prevention Quality Measure)

Description - Congestive heart failure (CHF) can be controlled in anoutpatient setting for the most part; however, the disease is a chronicprogressive disorder for which some hospitalizations are appropriate.

Rate Calculation - Calculated as number of admissions for CHF per100,000 population. Justification - Proper outpatient treatment may reduce admissions

for CHF and lower rates represent better quality care.

7. Dehydration Admission Rate(AHRQ Prevention Quality Measure)

Description - Dehydration is a serious acute condition that occurs infrail patients and patients with other underlying illnesses followinginsufficient attention and support for fluid intake.

Rate Calculation - Calculated as number of admissions for dehydrationper 100,000 population.

Justification - Proper outpatient treatment may reduce admissions fordehydration and lower rates represent better quality care.

8. Diabetes Admission Rate, long-term complications(AHRQ Prevention Quality Measure)

Description - Long-term complications of diabetes mellitus includerenal, eye, neurological and circulatory disorders. Long termcomplications occur at some time in the majority of patients withdiabetes to some degree. Diabetes can be associated with seriouscomplications and premature death.


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Rate Calculation - Calculated as number of admissions for diabetes(long term complications) per 100,000 population.

Justification- Proper outpatient treatment and adherence to prescribedcare may reduce the incidence of diabetic long term complications andlower rates represent better quality care.

9. Diabetes Admission Rate, short-term complications(AHRQ Prevention Quality Measure)

Description - Short term complications of diabetes mellitus includediabetic ketoacidosis, hyperosmolarity and coma. These life-threatening emergencies arise when a patient experiences an excess of

glucose (hyperglycemia) or insulin (hypoglycemia).

Rate Calculation - Calculated as number of admissions for diabetes(short term complications) per 100,000 population.

Justification - Proper outpatient treatment and adherence to prescribedcare may reduce the incidence of diabetic short term complications andlower rates represent better quality care.

10.Diabetes Admission Rate, uncontrolled(AHRQ Prevention Quality Measure)

Description - Uncontrolled diabetes should be used in conjunctionwith short term complications of diabetes, which include diabeticketoacidosis, hyperosmolarity and coma.

Rate Calculation - Calculated as number of admissions foruncontrolled diabetes per 100,000 population.

Justification - Proper outpatient treatment and adherence to prescribedcare may reduce the incidence of uncontrolled diabetes and lower rates

represent better quality care.

11. Hypertension Admission Rate(AHRQ Prevention Quality Measure)

Description - Hypertension is a chronic condition that is oftencontrollable in an outpatient setting with appropriate use of drugtherapy. Hypertension, also known as high blood pressure, is a


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medical condition in which there is narrowed room in the arteries,thereby causing difficulty in blood flow. The complications associatedwith hypertension increase the risk of heart attack, heart failure, strokeand kidney failure.

Rate Calculation - Calculated as number of admissions forhypertension in adults per 100,000 population.

Justification - Proper outpatient treatment may reduce admissions forhypertension and lower rates represent better quality care.

12. Low Birth Weight Admission Rate(AHRQ Prevention Quality Measure)

Description - Low birth weight infants are classified as those infantsborn weighing 5 pounds, 8 ounces or less (under 2,500 grams). Lowbirth weight is a significant health problem, contributing to infantmortality and long term developmental problems.

Rate Calculation - Calculated as the number of low birth weights as ashare of all births in an area.

Justification - Proper preventive care may reduce incidence of low birthweight and lower rates represent better quality care.

13. Pneumonia Admission Rate, Bacterial(AHRQ Prevention Quality Measure)

Description - Bacterial pneumonia is a relatively common acutecondition, treatable for the most part with antibiotics. If left untreatedin susceptible individuals, such as the elderly, pneumonia can lead todeath.

Rate Calculation - Calculated as number of admissions for bacterialpneumonia per 100,000 population.

Justification - Proper outpatient treatment may reduce admissionsfor bacterial pneumonia in non-susceptible individuals and lowerrates represent better quality care.


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14. Urinary Tract Infection (UTI) Admission Rate(AHRQ Prevention Quality Measure)

Description - Urinary tract infection is a common acute condition thatcan, for the most part, be treated with antibiotics in an outpatientsetting. However, this condition can progress to more clinicallysignificant infections, such as pyelonephritis, in vulnerable individualswith inadequate treatment.

Rate Calculation - Calculated as number of admissions for urinaryinfection per 100,000 population.

Justification - Proper outpatient treatment may reduce admissions forurinary infection and lower rates represent better quality care.


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B. Measure Definitions (reported by individual hospitals)1. Abdominal Aortic Aneurysm Repair (AAA)

(AHRQ Volume Measure)

Description - Abdominal aortic aneurysm (AAA) repair is a relativelyrare procedure that requires proficiency with the use of complexequipment; technical errors may lead to clinically significantcomplications, such as arrhythmias, acute myocardial infarction,colonic ischemia and death.

Volume Calculation - Raw volume of provider-level AAA repair. Justification - Higher volumes have been associated with betteroutcomes which represent better quality.

2. Acute Myocardial Infarction (AMI)(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - An acute myocardial infarction (heart attack) canresult when blood supply to the heart muscle is cut off. Cells in theheart muscle do not receive enough oxygen and begin to die. Themore time that passes without treatment to restore blood flow, thegreater the damage to the heart.

Rate Calculation - Calculated as the number of deaths per 100discharges for AMI.

Justification - Timely and effective treatments for acute myocardialinfarction (AMI), which are essential for patient survival, includeappropriate use of thrombolytic therapy and revascularization.

3. Carotid Endarterectomy (CEA)(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

Definition - Carotid endarterectomy is a surgical procedure thatremoves fatty buildup of plaque from the carotid artery. Thisprocedure has been widely used as a way to reduce stroke risk.

Rate Calculation - Calculated as number of deaths per 100 CEAs


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Justification - Carotid endarterectomy (CEA) is a fairly commonprocedure that requires proficiency with the use of complexequipment; technical errors may lead to clinically significantcomplications, such as abrupt carotid occlusion with or withoutstroke, myocardial infarction and death.

4. Carotid Endarterectomy (CEA)(AHRQ Volume Measure)

Definition - See CEA Risk-Adjusted Mortality Rate, Procedure Measure Volume Calculation - Raw volume of provider-level CEA Justification - Higher volumes have been associated with betteroutcomes, which represent better quality.

5. Congestive Heart Failure (CHF)(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - Congestive heart failure (CHF), or heart failure, is acondition in which the heart cannot pump enough blood to thebody's other organs. As blood flow out of the heart slows, bloodreturning to the heart through the veins backs up, causingcongestion in the tissues. Swelling (edema) often results.

Rate Calculation - Calculated as the number of deaths per 100discharges for CHF.

Justification - Congestive heart failure (CHF) is a progressive,chronic disease with substantial short term mortality, which variesfrom provider to provider.

6. Coronary Artery Bypass Graft (CABG)(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

Description - This procedure treats blocked heart arteries by creatingnew passages for blood to flow to your heart muscle. It works by takingarteries or veins from other parts of your body, called grafts, and usingthem to reroute the blood around the clogged artery.

Rate Calculation - Calculated as number of deaths per 100 CABGprocedures


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Justification - Coronary artery bypass graft (CABG) requires proficiencywith the use of complex equipment; technical errors may lead toclinically significant complications, such as myocardial infarction,stroke and death.

7. Coronary Artery Bypass Graft (CABG)(AHRQ Volume Measure)

Definition - See CABG Risk-Adjusted Mortality Rate, ProcedureMeasure

Volume Calculation - Raw volume of provider-level CABG. Justification - Higher volumes have been associated with betteroutcomes, which represent better quality.

8. Craniotomy Mortality(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

Description - A craniotomy is an operation, or surgery, on the brain.The surgeon makes an opening in the skull so that a brainoperation can be performed. A craniotomy may be done in any areaof the skull and may be almost any size.

Rate Calculation - Calculated as number of deaths per 100craniotomies

Justification - Craniotomy for the treatment of subarachnoidhemorrhage or cerebral aneurysm entails substantially high post-operative mortality rates.

9. Decubitus Ulcer Rate(AHRQ Patient Safety Measure)

Description - A decubitus ulcer, also called a pressure ulcer, is an areaof skin that breaks down when one position is held for too long withoutweight shiftment. This can occur in individuals that use wheelchairs orare bedridden, even for a short period of time (for example, aftersurgery or an injury). The constant pressure against the skin reducesthe blood supply to that area and the affected tissue dies.


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Rate Calculation - Decubitus ulcer rate is calculated using cases ofdecubitus ulcer per 1,000 discharges with a length of stay of four ormore days.

Justification - A decubitus ulcer starts as reddened skin but can getprogressively worse, forming a blister, then an open sore, and finally acrater. Damage can occur to tissues below the skin such as muscle,tendon, joint and bone.

10.Deep Vein Thrombosis (DVT) Rate, postoperative(AHRQ Patient Safety Measure)

Description - Deep vein thrombosis (DVT) refers to the formation of athrombus (blood clot) within a deep vein, commonly in the thigh orcalf.

Rate Calculation - Deep vein thrombosis rate is calculated as cases ofDVT per 1000 surgical discharges with an operating room procedure.

Justification - If the thrombus partially or completely blocks the flow ofblood through the vein, blood begins to pool and build-up below thesite, likely causing chronic swelling and pain. A thrombus can alsobreak free and travel through the veins reaching the lungs. Once in thelungs it is called a pulmonary embolism (PE), which is a potentiallyfatal condition that can kill within hours.

11. Gastrointestinal Hemorrhage (GI bleed)(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - Gastrointestinal bleeding refers to any bleeding thatstarts in the gastrointestinal tract, which extends from the mouth tothe large bowel. The degree of bleeding can range from nearlyundetectable to acute, massive and life-threatening.

Rate Calculation - Calculated as the number of deaths per 100discharges for GI hemorrhage. Justification - Gastrointestinal (GI) hemorrhage may lead to death

when uncontrolled; the ability to manage severely ill patients withcomorbidities may influence the mortality rate.


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12. Hip Fracture(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - If more pressure is put on a bone than it can stand, itwill split or break. A break of any size is called a fracture.

Rate Calculation - Calculated as the number of deaths per 100discharges for hip fracture.

Justification - Hip fractures, which are a common cause ofmorbidity and functional decline among elderly persons, areassociated with a significant increase in the subsequent risk ofmortality.

13. Hip Replacement(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

Description - Total hip arthroplasty (without hip fracture) is anelective procedure performed to improve function and relieve painamong patients with chronic osteoarthritis, rheumatoid arthritis, orother degenerative processes involving the hip joint.

Rate Calculation - Calculated as number of deaths per 100 hipreplacements.

Justification - Better processes of care may reduce mortality for hipreplacement, which represents better quality care.

14. Percutaneous Transluminal Coronary Angioplasty (PTCA)(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

Description - Percutaneous transluminal coronary angioplasty(PTCA) is performed on patients with coronary artery disease.PTCA involves threading a catheter (or balloon-tipped tube) from an

artery in the groin to a trouble spot in an artery of the heart. Theballoon is inflated so that the narrowed coronary artery can widenand allow blood to flow more easily. No ideal rate for PTCA hasbeen established.

Rate Calculation - Calculated as the number of deaths per 100PTCAs


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Justification - Percutaneous transluminal coronary angioplasty(PTCA) is a relatively common procedure that requires proficiencywith the use of complex equipment; technical errors may lead toclinically significant complications.

15. Percutaneous Transluminal Coronary Angioplasty (PTCA)(AHRQ Volume Measure)

Description - See PTCA Risk-Adjusted Mortality Rate, ProcedureMeasure

Volume Calculation - Raw volume of PTCA. Justification - Higher volumes have been associated with betteroutcomes, which represent better quality.

16.Pneumonia(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - Invasive disease caused by Streptococcus pneumoniae(pneumococcus) frequently manifests as bacteremia (bloodstreaminfections), pneumonia or meningitis. Antibiotic resistance hasbecome an increasing problem among isolates of S. pneumoniae.

Rate Calculation - Calculated as the number of deaths per 100discharges for pneumonia.

Justification - Treatment with appropriate antibiotics may reducemortality from pneumonia, which is a leading cause of death in theUnited States.

17. Pneumonia Infection Rate, ventilator-associated(IHI Measure)

Description - Ventilator-associated pneumonia (VAP) is defined asnosocomial pneumonia in a patient on mechanical ventilator support(by endotracheal tube or tracheostomy) for greater than or equal to 48hours.


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18. Pulmonary Embolism (PE) Rate, postoperative(AHRQ Patient Safety Measure)

Definition - A pulmonary embolus (PE) is a blockage of an artery in thelungs caused by fat, air, clumped tumor cells or a blood clot.

Rate Calculation - Pulmonary embolism rate is calculated as cases ofPE per 1000 surgical discharges with an operating room procedure.

Justification - Pulmonary embolus can cause severe injury or evendeath.

19.Sepsis Rate, postoperative(AHRQ Patient Safety Measure)

Definition - Sepsis is a severe illness caused by overwhelming infectionof the bloodstream by toxin-producing bacteria.

Rate Calculation - Sepsis rate is calculated as cases of sepsis per 1000elective surgery patients with an operating room procedure and alength of stay of four days or more.

Justification - Sepsis is often life-threatening, especially in people witha weakened immune system or other medical illnesses.

20.Stroke(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

Description - A stroke can occur when the blood supply to part ofthe brain is blocked or when a blood vessel in the brain bursts,causing damage to a part of the brain.

Rate Calculation - Calculated as the number of deaths per 100discharges for stroke.

Justification - Quality treatment for acute stroke must be timely andefficient to prevent potentially fatal brain tissue death, and patientsmay not present until after the fragile window of time has passed.


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C. Hospital Report Card Implementation Committee (current as of 5.15.07) Donna Kusuda (chair)

VP, Quality Improvement & Patient SafetyHCA/HealthONE

Scott AndersonVice President of Professional ActivitiesColorado Hospital Association

Crystal BerumenProject Director, Patient Safety InitiativesColorado Hospital Association

Lisa CampleseVP, Clinical Quality and Care CoordinationCentura Health

Cathy DillDirector of Quality ManagementEstes Park Medical Center

Gail Finley-RareyChief of Acute, Primary, Community-based Service and Occurrence

Reporting Section, Health Facilities and EMS DivisionColorado Department of Public Health and Environment

Teresa FisherPatient Safety SpecialistThe Childrens Hospital

Donna MarshallExecutive DirectorColorado Business Group on Health

Elaine MassieDirector of Quality Improvement / Risk ManagementPlatte Valley Medical Center

Kendra MoldenhauerManager, Patient Safety and QualityDenver Health


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Janet PogarDirector of ContractingAnthem Blue Cross

Danielle SeymourQuality Decision SupportExempla Healthcare

Judy SikesDirector of Accreditation / Medical Staff ServicesParkview Medical Center

Kristin StockerCoordinator of Regulatory AffairsUniversity of Colorado Hospital

Mack ThomasDirector, Performance ManagementCentura Health

Debbie Welle-PowellVice President, Payer Strategies & Legislative AffairsExempla Healthcare

Judy ZucconeDirector of Quality ServicesYampa Valley Medical Center


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D. Performance & Quality Coalition (current as of 5.15.07) Anthem Blue Cross Banner Health Colorado Department of Public Health and Environment COPIC Insurance Centers for Medicare and Medicaid Services Centura Health Colorado Association of Health Plans Colorado Business Group on Health Colorado Foundation for Medical Care Colorado Health Institute Colorado Hospital Association Colorado Medical Society Exempla Healthcare HCA/HealthONE Physician Health Partners Platte Valley Medical Center United Healthcare University of Colorado Hospital


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E. List of Common Acronyms AHRQ, Agency for Healthcare Research and Quality CDPHE, Colorado Department of Public Health and Environment CHA, Colorado Hospital Association CMS, Centers for Medicare and Medicaid Services HCAHPS, Hospital Consumer Assessment of Health Providers and

Systems Survey

HHS, U.S. Department of Health and Human Services IHI, Institute for Healthcare Improvement


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F. Relevant Links for Inclusion on Report Card Website Agency for Healthcare Research and Quality (AHRQ),

www.qualitymeasures.ahrq.gov

Centers for Disease Control (CDC), www.cdc.gov Centers for Medicaid and Medicare (CMS), www.cms.hhs.gov Institute for Healthcare Improvement (IHI), www.ihi.org The Joint Commission (JCAHO), www.jointcommission.org

Final Draft HRC

Documents

Transcript of Final Draft HRC