February 3, 2025 Release Notes

With this February release, QualityAdvisor is pleased to introduce a new Percentile Ranking Dashboard. This new addition to QualityAdvisor gives you an additional way to track your facility's performance against peer facilities by showing your percentile rankings at the outcome level, comparing your facility's (or facilities') O/E percentile ranking per outcome, against the O/E rankings of peer facilities for the same outcomes. We believe you will find this dashboard to be beneficial in many ways, including as you set your performance goals.

We have selected key CareScience risk-adjusted outcomes and PSI's (listed below) to include in the dashboard. You will see the O/E performance breakdown for each outcome across the 90th to the 10th percentiles for each facility you select, against peer O/E performance.

Dashboard Sample

Note: Data in the sample screen is not representative of actual data.

The dashboard includes the granular O/E percentile breakdown for the following CareScience Risk-adjusted Outcomes and Patient Safety Indicators:

Percentiles

Outcomes

90th 75th 60th 50th 25th 20th 10th

• All-Cause Hospital-Wide 30-Day Readmission (PRA v4.0 2022) O/E • All-Cause Hospital-Wide 30-Day Readmission (PRA v4.0 2023) O/E • All-Cause 30-Day Readmissions - All Inpatients O/E • Mortality O/E • Complications O/E • Geometric LOS O/E • Geometric Cost/Case O/E • PSI-02- Death in Low Mortality DRGs Rate/1000 (V2024) • PSI-03- Pressure Ulcer Rate/1000 (v2024) • PSI-04- Death in Surg Pts with Treatable Comp Rate/1000 (V2024) • PSI-05- Retained Surgical Item or Unretrieved Device Fragment Rate/1000 (V2024) • PSI-06- Iatrogenic Pneumothorax Rate/1000 (v2024) • PSI-07- Central Venous Catheter Related Blood Stream Infection Rate/1000 (V2024) • PSI-08- In Hospital Fall With Hip Fracture Rate/1000 (v2024) • PSI-09- Postoperative Hemorrhage or Hematoma Rate/1000 (v2024) • PSI-10- Postoperative Acute Kidney Injury Requiring Dialysis Rate/1000 (v2024) • PSI-11- Postoperative Respiratory Failure Rate/1000 (v2024) • PSI-12- Perioperative PE or DVT Rate/1000 (v2024) • PSI-13- Postoperative Sepsis Rate/1000 (v2024) • PSI-14- Postoperative Wound Dehiscence Rate/1000 (v2024) • PSI-15- Abdominopelvic Accidental Puncture or Laceration Rate/1000 (v2024) • PSI-17- Birth Trauma Injury to Neonate Rate/1000 (V2024) • PSI-18- OB Trauma Vaginal Delivery with Instrument Rate/1000 (V2024) • PSI-19- OB Trauma Vaginal Delivery w/o Instrument Rate/1000 (V2024)

Notes

• The outcome percentile rankings are based on CareScience analytics. 3M is not included

• As with all peer analytics in QualityAdvisor, you must choose at least five facilities and comply with the External Peer Methodology when selecting peers for your dashboard

• The dashboard is accessed via a link added to the QualityAdvisor toolbar. Click on the dashboard link in the toolbar and then click on the "Percentile Ranking Dashboard - Peer" link

Full details about the new Percentile Ranking Dashboard are available in Chapter 16 of the QualityAdvisor User Guide.

 

This February release includes the following Core Measure (EBC) updates:

Two measures are removed from QualityAdvisor

The following measures were previously retired and are now being removed/deleted from QualityAdvisor. Data for these measures has either already been archived, or will be archived as part of the upcoming summer 2025 release:

PC-03-Antenatal Steroids - Retired Dec 31, 2019 (EBC – TJC – PC Measure Rates)

PC-04-Health Care-Associated Bloodstream Infections in Newborns - Retired Dec 31, 2019 (EBC – TJC – PC Measure Rates)

Eight measures are retired (but not removed)

The measure descriptions for the following measures now include the date the measure is retired. The measures remain in QualityAdvisor for reporting purposes:

ACHF-01- Beta-Blocker Therapy for LVSD Prescribed at Discharge - Retired Dec 31, 2024 (EBC - TJC – ACHF Measure Rates)

ACHFOP-01- Hospital Outpatient Beta-Blocker Therapy Prescribed for LVSD - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-02- Hospital Outpatient ACEI or ARB Prescribed for LVSD - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-03- Hospital Outpatient Mineralocorticoid Receptor Antagonists (MRA) - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-04- Hospital Outpatient New York Heart Association (NYHA) Classification Assessment - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-05- Hospital Outpatient Activity Recommendations - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-06- Hospital Outpatient Discussion of Advance Directives/Advance Care Planning - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

ACHFOP-07- Hospital Outpatient Advance Directive Executed - Retired Dec 31, 2024 (EBC - TJC - OP-ACHF Measure Rates)

4 Measure Descriptions Updated

OP-AMI-3a-Median Time to Xfer to Another Facility for Acute Coronary Intervention – Overall – Retired Dec 31, 2024 (EBC – CMS – OP-AMI Continuous Measures)

OP-AMI-3b-Median Time to Xfer to Another Facility for Acute Coronary Intervention – Rpt – Retired Dec 31, 2024 (EBC – CMS – OP-AMI Continuous Measures)

OP-AMI-3c-Median Time to Xfer to Another Facility for Acute Coronary Intervention – QI – Retired Dec 31, 2024 (EBC – CMS – OP-AMI Continuous Measures)

OP-AMI-2-Fibrinolytic Therapy Received Within 30 Minutes – Retired Dec 31, 2024 (EBC – CMS – OP-AMI Measure Rates)

Nine Measures are Added

The following IPFQR SDOH measures are effective 1/1/2025, and the THA/TKA PRO-PM measures are effective 7/1/2024:

IPFQR - SDOH-1- Screening for Social Drivers of Health (EBC - CMS IPFQR - SDOH Measure Rates)

IPFQR - SDOH-2a- Screen Positive Rate for Social Drivers of Health - Food Insecurity (EBC - CMS IPFQR - SDOH Measure Rates)

IPFQR - SDOH-2b- Screen Positive Rate for Social Drivers of Health - Housing Instability (EBC - CMS IPFQR - SDOH Measure Rates)

IPFQR - SDOH-2c- Screen Positive Rate for Social Drivers of Health - Transportation Needs (EBC - CMS IPFQR - SDOH Measure Rates)

IPFQR - SDOH-2d- Screen Positive Rate for Social Drivers of Health - Utility Difficulties (EBC - CMS IPFQR - SDOH Measure Rates)

IPFQR - SDOH-2e- Screen Positive Rate for Social Drivers of Health - Interpersonal Safety (EBC - CMS IPFQR - SDOH Measure Rates)

THA/TKA PRO-1- Overall Survey Response Rate (EBC - CMS - THA/TKA PRO-PM Measure Rates)

THA/TKA PRO-1a- Pre-Operative Survey Response Rate (EBC - CMS - THA/TKA PRO-PM Measure Rates)

THA/TKA-PRO-1b- Post-Operative Survey Response Rate (EBC - CMS - THA/TKA PRO-PM Measure Rates)