March 27, 2023 Release Notes

Expand any topic listed below to see the details included in this release

 

The QualityAdvisor application includes the following peer group categories:

  • Top Performer Peers

  • Academic Peers

  • Birth Volume Peers

  • Blood Utilization Peer Group

  • QUEST Peer Groups

  • Safety Net Peer Group

Peer Groups are updated annually in the application, typically with the March release. The updates included in this March release are listed below:

Top Performers

2022 Top Performers are now available in each of the following categories:

Top Performer Peers – Overall by Focused Population

Top Performer Peers – by Outcome

Top Performer Peers – Overall

Please see Current Top Performer Peer Groups in chapter 11 of the Methodologies User Guide for details.

Notes:

All 2022 Top Performers are calculated based on data from the January - December 2021 timeframe

The Top Performers by Focused Population based on the CMS Readmission and Mortality methodologies were calculated using the FY23 focused population definitions

The update includes 2022 Outpatient Top Decile and Top Quartile Performers

2022 Readmission Top Performer peers are based on HWR v4.0 2021 readmission methodology

All 2018 Top Performer Peers are retired

Academic Peer Group Update

The Academic Peer Group is now updated. Each year, the new peer list completely replaces the previous year's list.

Note: The qualifying definition for the Academic Peer Group stipulates that the peer group only includes facilities that are active QualityAdvisor members who are published on the Association of American Medical Colleges (AAMC) website, and that meet minimum comparative publishing standards to the comparative warehouse. Since the Academic Peer Group is updated only once every 12 months, it is possible that the list may or may not include facilities whose status against the qualifying definition has changed in the ensuing 12 months.

Birth Volume Peers

All groups in the Birth Volume peer group have been recalculated to be based on calendar year 2021 values. The methodology used to identify birth volumes for each facility matches the CDC Birth Volume denominator methodology.

Blood Utilization Peer Group

A new 2022 Blood Utilization & Data Optimization peer group has been added to the Premier Initiatives folder.

The 2018 peer group is retired

QUEST Peer Groups

A new All QUEST 6.0 Hospitals peer group is added.

All QUEST 5.0 peer groups remain

The QUEST 2020 peer groups is retired

Safety Net Peer Group

The Safety Net Hospitals Peer Group is now updated. Each year, the new peer list completely replaces the previous year's list.

A safety net hospital is a type of medical center (in the United States) that, by legal obligation or mission, provides healthcare for all individuals regardless of their insurance status or ability to pay. The Safety Net Hospitals peer group at Premier, includes active members of the America’s Essential Hospitals (AEH) trade group that helps ensure access to care for America’s medically under-served and uninsured populations, and are published on the AEH Website.

 

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

Five 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 2023 release:

OP-1 — Median Time to Fibrinolysis — Retired Mar 31, 2018

OP-4 (AMI) Aspirin at Arrival — AMI Retired Mar 31, 2018

OP-4 (CP) Aspirin at Arrival — CP Retired Mar 31, 2018

OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel (min) — Retired Mar 31, 2018

OP-21 Median Time to Pain Management for Long Bone Fracture — Retired Mar 31, 2018

Nine 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:

HBIPS-1a-Violence Risk, Substance Use, Trauma, Patient Strengths Screening-Overall Den — Retired December 31, 2022

HBIPS-1b-Violence Risk, Substance Use, Trauma, Patient Strengths Screening-1 to 12 years Den — Retired December 31, 2022

HBIPS-1c-Violence Risk, Substance Use, Trauma, Patient Strengths Screening-13 to 17 years Den — Retired December 31, 2022

HBIPS-1d-Violence Risk, Substance Use, Trauma, Patient Strengths Screening-18 to 64 years Den — Retired December 31, 2022

HBIPS-1e-Violence Risk, Substance Use, Trauma, Patient Strengths Screening- >=65 yrs Den — Retired December 31, 2022

OP-AMI.-2-Fibrinolytic Therapy Received Within 30 Minutes Den — Retired March 31, 2023

OP-AMI-3a-Median Time to Xfer to Another Facility for Acute Coronary Intervention - Overall — Retired March 31, 2023

OP-AMI-3b-Median Time to Xfer to Another Facility for Acute Coronary Intervention - Rpt — Retired March 31, 2023

OP-AMI-3c-Median Time to Xfer to Another Facility for Acute Coronary Intervention - QI — Retired March 31, 2023

66 measures are added

With this March release, we are adding 66 measures from Quality Measures Reporter. The new patient level metrics are added to Custom Query, and include CMS-specific measures and certification measures. Some of these measures already existed in QualityAdvisor for other program initiatives, but some of the newly added measures represent a different population (denominator), such as the CMS Inpatient Psychiatric Facility Quality Reporting (IPFQR) measures.

The addition of these measures serve to better align QualityAdvisor and Quality Measures Reporter.

  • ACHF-01 — Beta-Blocker Therapy for LVSD Prescribed at Discharge

  • ACHF-02 — Post-Discharge Appointment for Heart Failure Patients

  • ACHF-03 — Care Transition Record Transmitted

  • ACHF-04 — Discussion of Advance Directives/Advance Care Planning

  • ACHF-05 — Advance Directive Executed

  • ACHF-06 — Post-Discharge Evaluation for Heart Failure Patients

  • ACHFOP-01 — Hospital Outpatient Beta-Blocker Therapy Prescribed for LVSD

  • ACHFOP-02 — Hospital Outpatient ACEI or ARB Prescribed for LVSD

  • ACHFOP-03 — Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD

  • ACHFOP-04 — Hospital Outpatient New York Heart Association (NYHA) Classification Assessment

  • ACHFOP-05 — Hospital Outpatient Activity Recommendations

  • ACHFOP-06 — Hospital Outpatient Discussion of Advance Directives/Advance Care Planning

  • ACHFOP-07 — Hospital Outpatient Advance Directive Executed

  • ASR-IP-1 — Thrombolytic Therapy: Inpatient Admission

  • ASR-IP-2 — Antithrombotic Therapy By End of Hospital Day 2

  • ASR-IP-3 — Discharged on Antithrombotic Therapy

  • ASR-OP-1 — Thrombolytic Therapy: Drip and Ship

  • CSTK-01 — National Institutes of Health Stroke Scale

  • CSTK-02 — Modified Rankin Score (mRS at 90 Days)

  • CSTK-03 — Severity Measurement Performed for SAH and ICH Patients (Overall Rate)

  • CSTK-03a — Hunt and Hess Scale Performed for SAH Patients

  • CSTK-03b — ICH Score Performed for ICH Patients

  • CSTK-04 — Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH)

  • CSTK-05 — Hemorrhagic Transformation (Overall Rate)

  • CSTK-05a — Hemorrhagic Transformation for Patients Treated with Intra-Venous (IV) Alteplase Therapy Only

  • CSTK-05b — Hemorrhagic Transformation for Patients Treated with Intra-Arterial (IA) Alteplase Therapy or Mechanical Endovascular Reperfusion Therapy

  • CSTK-06 — Nimodipine Treatment Administered

  • CSTK-08 — Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)

  • CSTK-09 — Arrival Time to Skin Puncture (Overall Rate)

  • CSTK-09a — Arrival Time to Skin Puncture (Transfer from Another Hospital)

  • CSTK-09b — Arrival Time to Skin Puncture (Direct Admit or Mode of Arrival UTD)

  • CSTK-10 — Modified Rankin Score (mRS at 90 Days: Favorable Outcome)

  • CSTK-10a — Functional Status Prior to Stroke-Independent: IV Alteplase Only

  • CSTK-10b — Functional Status Prior to Stroke-Dependent: IV Alteplase Only

  • CSTK-10c — Functional Status Prior to Stroke-Independent: MER Therapy

  • CSTK-10d — Functional Status Prior to Stroke-Dependent: MER Therapy

  • CSTK-11 — Rate of Rapid Effective Reperfusion From Hospital Arrival

  • CSTK-12 — Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

  • HBIPS-5 (CMS IPFQR) — Multiple Antipsychotic Medications at Discharge with Appropriate Justification

  • IMM-2 (CMS IPFQR) — Influenza Immunization

  • OP-29 — Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

  • PC-01 (CMS IQR) — Elective Delivery

  • *SEP-SHK-3HR — SEP-SHK-3HR Septic Shock 3HR Bundle

  • *SEP-SHK-6HR — SEP-SHK-6HR Septic Shock 6HR Bundle

  • *SEV-SEP-3HR — SEV-SEP-3HR Severe Sepsis 3HR Bundle Den

  • *SEV-SEP-6HR — SEV-SEP-6HR Severe Sepsis 6HR Bundle

  • SMD — Screening for Metabolic Disorders

  • STK-OP-1a — Median Time Door to Transfer Overall Rate

  • STK-OP-1b — Median Time Door to Transfer Hemorrhagic Stroke

  • STK-OP-1c — Median Time Door to Transfer Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship)

  • STK-OP-1d — Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible

  • STK-OP-1e — Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible

  • STK-OP-1f — Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO

  • STK-OP-1g — Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible

  • STK-OP-1h — Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible

  • STK-OP-1i — Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO

  • STK-VOL-1 — Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy

  • SUB-2 (CMS IPFQR) — Alcohol Use Brief Intervention Provided or Offered

  • SUB-2a (CMS IPFQR) — Alcohol Use Brief Intervention

  • SUB-3 (CMS IPFQR) — Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge

  • SUB-3a (CMS IPFQR) — Alcohol and Other Drug Use Disorder Treatment at Discharge

  • TOB-2 (CMS IPFQR) — Tobacco Use Treatment Provided or Offered

  • TOB-2a (CMS IPFQR) — Tobacco Use Treatment

  • TOB-3 (CMS IPFQR) — Tobacco Use Treatment Provided or Offered at Discharge

  • TOB-3a (CMS IPFQR) — Tobacco Use Treatment at Discharge

  • TR-1 — Transition Record with Specified Elements Received by Discharged Patients

* The SEP-1 bundle measures will be calculated for patients discharged on or after July 1, 2021. This is due to CMS changing the measure algorithm effective with July 1, 2021 discharges.

 

 

We have updated the folder structure within Custom Query's Columns prompt (on Set Up Analysis tab) for EBC measures to include the initiative a measure belongs to (CMS, TJC, or none).

For measures that are specific to only one initiative, (CMS or TJC) and have no overlap, the initiative is displayed in both the folder description, and measure description within the folder.

For the folder structure, the initiative is displayed after "EBC," for example:

EBC - CMS - PC Measure Rates

EBC - TJC - PC Measure Rates

For the measure description, the initiative is in front of the measure description, for example:

CMS - PC-01- Elective Delivery

TJC - PC-01- Elective Delivery

The initiative is not listed in the prompt folder or measure description for measures that overlap and exist for both CMS and TJC initiatives.

 

 

 

 

 

Go to the Archives to see Release Notes for previous releases