Specifications Manual for Joint Commission National Quality Measures (v2018B1)

Release Notes:
Measure Information Form
Version 2018B1

Measure Information Form

Measure Set: Advanced Certification Heart Failure Outpatient (ACHFOP)

Set Measure ID: ACHFOP-05

Performance Measure Name: Hospital Outpatient Activity Recommendations

Description: Outpatients who have received a document describing individualized activity recommendations including type of activity, duration and intensity, tailored to their needs. This document must be present in the outpatient record.

Rationale: Heart failure is a progressive clinical syndrome in which damage to the myocardium impairs the ability of the ventricle to effectively pump blood throughout the body. It manifests by fluid congestion or inadequate blood flow to tissues. Dyspnea and fatigue are cardinal signs of the disease, which may limit exercise tolerance, and negatively impact the quality of life.

The Committee on Exercise, Rehabilitation, and Prevention of the American Heart Association Council on Clinical Cardiology has concluded that exercise training in patients with heart failure seems to be safe and beneficial overall in improving exercise capacity, as measured by peak VO2, peak workload, exercise duration, and parameters of submaximal exercise performance. Although studies addressing quality of life for heart failure patients participating in an exercise program are limited, findings suggest that quality of life improves proportionately with increased exercise capacity. Since there is currently a lack of consensus as to a universal exercise protocol for all heart failure patients, exercise programs should be tailored to the needs of the individual. Recommendations for exercise should include the setting, type of activity, duration, and intensity (Piña et al., 2003).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Outpatients who have received a document describing individualized activity recommendations including ALL of the following:
  • Type of activity
  • Duration of activity
  • Intensity of activity
This document must be present in the outpatient record.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: All heart failure patients
Included Populations:
  • E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0, and
  • An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Excluded Populations:
  • Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A, Table 2.2)
  • Patients less than 18 years of age
  • Patients enrolled in clinical trials
  • Patients with a documented Reason for No Activity Recommendations in the Outpatient Setting

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  1. Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstan MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):e391-e479.
  2. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK, Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16(6):475-539.
  3. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327.

Measure Algorithm:

Measure Information Form ACHFOP-05
Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)

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