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Table Of Contents
Version 2010A1

Specifications Manual for National Hospital Inpatient Quality Measures

Section 1: Introduction to the Data Dictionary

Section 2: Measurement Information Forms

  • Acute Myocardial Infarction (AMI)
    • 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-6 - Beta-Blocker at Arrival
    • AMI-7 - Median Time to Fibrinolysis
    • AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
    • AMI-8 - Median Time to Primary PCI
    • AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
    • AMI-9 - Inpatient Mortality
    • AMI-T1a - LDL Cholesterol Assessment (Optional Test Measure)
    • AMI-T2 - Lipid-Lowering Therapy at Discharge (Optional Test Measure)
  • Heart Failure (HF)
    • HF-1 - Discharge Instructions
    • HF-2 - Evaluation of LVS Function
    • HF-3 - ACEI or ARB for LVSD
    • HF-4 - Adult Smoking Cessation Advice/Counseling
  • Pneumonia (PN)
    • PN-2 - Pneumococcal Vaccination
    • PN-7 - Influenza Vaccination
    • 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 in Hospital
    • PN-4 - Adult Smoking Cessation Advice/Counseling
    • PN-5 - Antibiotic Timing (Median)
    • PN-5a - Initial Antibiotic Received Within 8 Hours of Hospital Arrival - RETIRED
    • PN-6b - Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Non ICU Patients
    • PN-5b - Initial Antibiotic Received Within 4 Hours of Hospital Arrival
    • PN-5c - Initial Antibiotic Received Within 6 Hours of Hospital Arrival (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
    • PN-6 - Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
    • PN-6a - Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Intensive Care Unit (ICU) Patients
  • Pregnancy and Related Conditions (PR)
    • PR-1 - VBAC
    • PR-2 - Inpatient Neonatal Mortality
    • PR-3 - Third or Fourth Degree Laceration
  • Surgical Care Improvement Project (SCIP)
    • SCIP-Inf-1a - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate
    • SCIP-Inf-1b - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG
    • SCIP-Inf-1c - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery
    • SCIP-Inf-1d - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
    • SCIP-Inf-1e - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty
    • SCIP-Inf-1f - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery
    • SCIP-Inf-1g - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy
    • SCIP-Inf-1h - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery
    • SCIP-Inf-2a - Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate
    • SCIP-Inf-2b - Prophylactic Antibiotic Selection for Surgical Patients - CABG
    • SCIP-Inf-2c - Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery
    • SCIP-Inf-2d - Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty
    • SCIP-Inf-2e - Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty
    • SCIP-Inf-2f - Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery
    • SCIP-Inf-2g - Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy
    • SCIP-Inf-2h - Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery
    • SCIP-Inf-3a - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Overall Rate
    • SCIP-Inf-3b - Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time – CABG
    • SCIP-Inf-3c - Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac Surgery
    • SCIP-Inf-3d - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty
    • SCIP-Inf-3e - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty
    • SCIP-Inf-3f - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery
    • SCIP-Inf-3g - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time – Hysterectomy
    • SCIP-Inf-3h - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery
    • 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-7 - Colorectal Surgery Patients with Immediate Postoperative Normothermia
    • SCIP-Card-2 - Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period
    • SCIP-venous-thromboembolism-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
    • SCIP-venous-thromboembolism-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
    • 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
  • Children’s Asthma Care (CAC)
    • CAC-1a - Relievers for Inpatient Asthma (age 2 through 17 years) – Overall Rate
    • CAC-1b - Relievers for Inpatient Asthma (age 2 through 4 years)
    • CAC-1c - Relievers for Inpatient Asthma (age 5 through 12 years)
    • CAC-1d - Relievers for Inpatient Asthma (age 13 through 17 years)
    • CAC-2a - Systemic Corticosteroids for Inpatient Asthma (age 2 through 17 years) – Overall Rate
    • CAC-2b - Systemic Corticosteroids for Inpatient Asthma (age 2 through 4 years)
    • CAC-2c - Systemic Corticosteroids for Inpatient Asthma (age 5 through 12 years)
    • CAC-2d - Systemic Corticosteroids for Inpatient Asthma (age 13 through 17 years)
    • CAC-3 - Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
    • CAC-2 - Systemic Corticosteroids for Inpatient Asthma
    • CAC-1 - Relievers for Inpatient Asthma

Section 3: Missing and Invalid Data

Section 4: Population and Sampling Specifications

Section 5

  • Reserved for Future Use

Section 6

  • Reserved for Future Use

Section 7

  • Reserved for Future Use

Section 8: National Hospital Quality Measure Verification Process

  • National Hospital Quality Measure Verification Process (The Joint Commission Performance Measurement Systems Only). This section has been moved to the ORYX Data Quality Manual and is available to performance measurement systems via the Joint Commission’s extranet site for measurement systems (PET).

Section 9: National Hospital Quality Measure Data Transmission

Section 10: CMS Risk-Adjusted 30-Day Mortality Measures

  • CMS Risk-Adjusted 30-Day Mortality Measures

Appendices

Table Of Contents
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)