How Medicare Measures Hospital Quality

There are many ways that Medicare evaluates hospital quality. Medicare conducts patient surveys (i.e,. HCAHPS). Medicare has hospitals report a variety of process of care measures through the Inpatient Quality Report (IQR) Program. Medicare uses data that Centers for Disease Control and Prevention (CDC) collects via the National Healthcare Safety Network (NHSN) tool to measure hospital-acquired infection (HAI) rates.

In addition to these initiatives, there are five main ways that Medicare evaluates hospital quality using claims data: (i) AHRQ patient safety and inpatient quality indicators; (ii) hospital acquired conditions, (iii) mortality, (iv) readmissions, and (v) spending per beneficiary. A list of the quality measures that fall under each category are listed below.

AHRQ Measures

• PSI 04 – Death among surgical inpatients with serious treatable complications
• PSI 06 – Iatrogenic pneumothorax
• PSI 11 – Postoperative respiratory failure
• PSI 12 – Postoperative pulmonary embolism or deep vein thrombosis
• PSI 14 – Postoperative wound dehiscence
• PSI 15 – Accidental puncture or laceration
• PSI 90 composite – Patient safety for selected indicators
• IQI 11 – Abdominal aortic aneurysm (AAA) repair mortality
• IQI 19 – Hip fracture mortality
• IQI 91 composite – Mortality for selected conditions

For more information see QualityNet or the AHRQ website.

Hospital Acquired Conditions

1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Pressure ulcer stages III and IV
5. Falls and trauma, including: Fractures, Dislocations, Intracranial injuries, Crushing injuries, Burns, Other injuries
6. Vascular catheter-associated infection
7. Catheter-associated urinary tract infection
8. Manifestations of poor glycemic control, including: diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity

There is one more complication CMS added: Complication Rate Following Elective Primary THA and/or TKA.

For more information see QualityNET HACs.

Mortality

• 30-day mortality measures for Acute Myocardial Infarction
• 30-day mortality measures for Heart Failure
• 30-day mortality measures for Heart Failure Pneumonia

Readmissions

• All-cause 30-day readmissions for acute myocardial infarction (AMI),
• All-cause 30-day readmissions for heart failure (HF),
• All-cause 30-day readmissions for pneumonia (PN)
• Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)
• 30-Day All-Cause Risk-Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Spending

• Medicare Spending per Beneficiary (MSPB) – assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge.