Patient Safety

These resources focus on quality improvement related to patient safety and inpatient care. The current MBQIP measures that fall under this domain are HCP/IMM-3 and Antibiotic Stewardship. Safe Use of Opioids (eCQM) will be added as soon as data is received.

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View the patient safety report of your hospital by entering its CCN below.

View the patient safety report of your hospital

Reports

The MBQIP Patient Safety and Inpatient Care Quality Reports include data from CMS Hospital Compare measures that are relevant for CAHs under the MBQIP domains of patient safety/inpatient care. The reports include data from all CAHs that have signed a MBQIP Memorandum of Understanding (MOU) and have submitted data. Thus, the reports include data from CAHs that have not agreed to publicly report on Hospital Compare, in addition to data from CAHs that don’t have enough cases to be publically reported on Hospital Compare, providing a more complete picture of performance across CAHs nationally.

Using Compairson Data for Patient Safety and Inpatient/Outpatient Measures

MBQIP Patient Safety and Inpatient/Outpatient Care Quality Reports summarize process-based quality measures that evaluate implementation of clinically proven best practices of care. Hospitals should strive to provide these best practices in clinical care to every patient, 100 percent of the time. Each measure includes the following comparison groups:

all reporting CAHs by state, under the column header CAH State Current Quarter
all reporting CAHs nationally, under the column header CAH National Current Quarter
all reporting hospitals nationally (both Prospective Payment System hospitals and CAHs), under the column header All National Current Quarter (unavailable for Antibiotic Stewardship)

Although it can be helpful to understand performance in comparison to those norms, averages represent the middle ground for performance and everyone should strive to achieve at least the 90^th percentile for each measure. For quality improvement purposes, such data benchmarks are more useful than average comparison data.

Measure Information

HCP/IMM-3

Influenza Vaccination Coverage Among Healthcare Personnel (HCP)

Encounter Period

October 1, 20XX – March 31, 20XX (Aligns with flu season, for example: October 1, 2023 – March 31, 2024)

Submission Deadline

May 15, 20XX
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter where applicable.

Measure Description

Influenza Vaccination Coverage among Healthcare Personnel

Measure Rationale

1 in 5 people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributed to patients hospitalized during the flu season.

Improvement Noted As

Increase in the rate (percent)

Numerator

All HCP personnel who:

Received vaccination at the facility
Received vaccination outside of the facility
Did not receive vaccination due to contraindication
Did not receive vaccination due to declination

Denominator

All HCP that worked in the facility (part-time or full-time) for at least one day during the encounter period of October 1 – March 31.

Measure Population (Determines the cases to abstract/submit)

All HCP that worked in the facility (part-time or full-time) for at least one day during the encounter period of October 1 – March 31.

Sample Size Requirements

No sampling - report all cases

Calculations

All data reporting is aggregate (whether monthly, once a season, or at a different interval)

Data Source

Administrative Data

Data Collection Approach

Hospital Tracking

Data Elements

Three categories (all with separate denominators) of HCP working in the facility at least one day between 10/1-3/31:

Employees on payroll
Licensed independent practitioners
Students, trainees, and volunteers 18yo+

A fourth optional category is available for reporting other contract personnel. HCP workers who:

Received vaccination at the facility
Received vaccination outside of the facility
Did not receive vaccination due to contraindication
Did not receive vaccination due to declination

Measure Submission and Reporting Channel

This data is reported annually through the Healthcare Personnel Safety Component of National Healthcare Safety Network (NHSN) website.

Data Available On

MBQIP Data Reports

Other Notes

Each facility in a system needs to be registered separately and HCPs should be counted in the sample population for every facility at which they work. Facilities must complete a monthly reporting plan for each year or data reporting period. All data reporting is aggregated (whether monthly, once a season, or at a different interval).

Antibiotic Stewardship

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Annual Survey

Encounter Period

Calendar Year (January 1, 20XX – December 31, 20XX)

Submission Deadline

March 1, 20XX
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter where applicable.

Measure Description

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Annual Survey

Measure Rationale

Improving antibiotic use in hospitals is imperative to improving patient outcomes, decreasing antibiotic resistance, and reducing healthcare costs. According to the Centers for Disease Control and Prevention (CDC), 20-50 percent of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, which leads to serious side effects such as adverse drug reactions and Clostridium difficile infection. Overexposure to antibiotics also contributes to antibiotic resistance, making antibiotics less effective.

In 2014, CDC released the “Core Elements of Hospital Antibiotic Stewardship Programs,” which identifies key structural and functional aspects of effective programs and elements designed to be flexible enough to be feasible in hospitals of any size.

Improvement Noted As

Increase in the number of core elements met

Measure Population

NA – This measure uses administrative data and not claims to determine the measure’s denominator population.

Sample Size Requirements

No sampling – report all information as requested

Data Collection Approach

Hospital tracking

Data Elements

Questions as answered on the Patient Safety Component Annual Hospital Survey inform whether the hospitals have successfully implemented the following core elements of antibiotic stewardship:

Leadership
Accountability
Drug Expertise
Action
Tracking
Reporting
Education

Measure Submission and Reporting Channel

National Healthcare Safety Network (NHSN) website

Safe Use of Opioids (eCQM)

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on two or more opioids, or an opioid and benzodiazepine concurrently at discharge.

Encounter Period

Calendar Year (January 1, 20XX – December 31, 20XX)

Submission Deadline

February 28, 20XX
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter.

Measure Rationale

Unintentional opioid overdose fatalities have become an epidemic and major public health concern in the United States. Concurrent prescriptions of opioids, or opioids and benzodiazepines, places patients at a greater risk of unintentional overdose due to increased risk of respiratory depression. Patients who have multiple opioid prescriptions have an increased risk for overdose, and rates of fatal overdose are ten (10) times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone. A measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce costs associated with adverse events related to opioids.

Measure Program Alignment

Safe Use of Opioids is a current measure of the Medicare Promoting Interoperability (PI) Program. Critical access hospitals must meet PI Program requirements on an annual basis to avoid a downward payment. One of the program requirements is submission of electronic clinical quality measures (eCQM) data from certified electronic health record technology (CEHRT). Calendar year (CY) 2023 eCQM reporting requirements for PI include data reflecting all four quarters of CY 2023 for:

Three self-selected measures of the thirteen available eCQMs for each quarter
One required measure: Safe Use of Opioid Measure

Improvement Noted As

Decrease in the rate

Numerator

Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge

Denominator

Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge.

Exclusions

Inpatient hospitalizations where patients have cancer that begins prior to or during the encounter or are ordered or are receiving palliative or hospice care (including comfort measures, terminal care, and dying care) during the hospitalization or in an emergency department encounter for observation stay immediately prior to hospitalization, patients discharged to another inpatient care facility, and patients who expire during the inpatient stay.

Measure Population (Determines the cases to abstract/submit)

Sample Size Requirements

No sampling – report all patients that meet data elements

Calculations

Numerator divided by Denominator

Data Source

Certified electronic health record technology (CEHRT)

Data Collection Approach

Electronic Extraction from EHRs via Quality Reporting Document Architecture (QRDA) Category I File

Measure Submission and Reporting Channel

Annually, via Hospital Quality Reporting (HQR) Secure Portal as any combination of: QRDA Category I File, zero denominator declarations and/or case threshold exemptions (<=5 cases in the reporting quarter)