The VHHA quality and safety consensus measures selected are:

1) Healthcare-Associated Infections:

  • Central Line-Associated Blood Stream Infection (CLABSI)
  • Catheter-Associated Urinary Tract Infections (CAUTI)

2) PSI-90 Complication/Patient Safety for Selected Indicators

3) Readmission 30-Day (All) for Acute Myocardial Infarction, Heart Failure, Pneumonia, Hip/Knee and 30-Day Hospital All-Cause Unplanned

4) Mortality 30-Day for Acute Myocardial Infarction, Heart Failure, and Pneumonia

5) Patient Satisfaction: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

  • Patients who gave their hospital a rating of 9 or 10 (Raw Score)

6) Efficiency: Medicare Spending Per Beneficiary

Descriptive information about the measures selected and currently reported is provided below.


About the measures selected

1) Healthcare-Associated Infections

Healthcare-associated infections, or HAIs, are infections that people acquire while they are receiving treatment for another condition in a health care setting. HAIs can be acquired anywhere health care is delivered, including inpatient acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal disease centers, and long-term care facilities such as nursing homes and rehabilitation centers. HAIs may be caused by any infectious agent, including bacteria, fungi and viruses, as well as other less common types of pathogens.

Central Line-Associated Bloodstream Infection (CLABSI)

CLABSIs fall within a general category of primary bloodstream infections that are associated with the presence of a central line at the time or before the onset of the infection. The term primary bloodstream infection refers to those in which there is no obvious source. These are serious complications in that they typically cause a prolongation of hospital stay and increased cost and risk of mortality. The data in the report include CLABSIs that occur in the ICU setting.

Data Source: Virginia Department of Health
Data Timeframe: CLABSI data represent a rolling 12-month reporting

Catheter-Associated Urinary Tract Infection (CAUTI)

A catheter-associated urinary tract infection (CAUTI) occurs when germs (usually bacteria) enter the urinary tract through the urinary catheter and cause infection. CAUTIs have been associated with increased morbidity, mortality, healthcare costs, and length of stay. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible; that catheters are placed using proper aseptic technique; and that the closed sterile drainage system is maintained.

Data Source: The Centers for Medicare & Medicaid Services


2) PSI-90 Complication/Patient Safety Selected Indicators

Patient Safety Indicator (PSI) 90 measure is an administrative claims based measure developed by the Agency for Healthcare Research and Quality (AHRQ). PSI-90 is a composite measures of eight (8) AHRQ measures of hospital-acquired conditions: 1) PSI-03 Pressure Ulcer; 2) PSI-06 Iatrogenic Pneumothorax; 3) PSI-07 Central Venous Catheter-related Bloodstream Infections; 4) PSI-08 Postoperative Hip Fracture; 5) PSI-12 Postoperative Pulmonary Embolism or Deep Venous Thrombosis; 6) PSI-13 Postoperative Sepsis; 7) PSI-14 Postoperative Wound Dehiscence; and 8) PSI-15 Accidental Puncture or Laceration. The presentation of the data on the VHHA scorecard is designed to mirror the presentation of the data on the CMS Hospital Compare web site.

Data Source: The Centers for Medicare & Medicaid Services


3) Readmission (30-Days)

Readmission is defined as any admission to the same hospital occurring within 30 days after discharge from the initial visit. The data included here are risk adjusted, and include information on heart attack, heart failure, pneumonia, hip/knee surgery patients and 30-day hospital all-cause unplanned. The presentation of the data on the VHHA scorecard is designed to mirror the presentation of the data on the CMS Hospital Compare web site, which incorporates a confidence interval to determine the color-coding scheme.

Data Source: The Centers for Medicare & Medicaid Services


4) Mortality (30-Days)

Mortality is defined as death occurring within 30 days of a hospital admission. The data included here are risk adjusted, and include information on heart attack, heart failure and pneumonia patients.

Data Source: The Centers for Medicare & Medicaid Services


5) Patient Experience

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally. The HCAHPS measure included on the scorecard is “How do patients rate the hospital overall?” (9 or 10)

Data Source: The Centers for Medicare & Medicaid Services


6) Efficiency: Medicare Spending Per Beneficiary

The Medicare Spending per Beneficiary (MSPB) Measure evaluates hospitals’ efficiency, as reflected by Medicare payments made during an MSPB episode, relative to the efficiency of the median hospital. An MSPB episode includes all Medicare Part A and Part B claims paid during the period from 3 days prior to a hospital admission (i.e., index admission) through 30 days after discharge from the hospital. A hospital’s MSPB Measure is calculated as the hospital’s average MSPB Amount divided by the median MSPB Amount across all hospitals, where a hospital’s MSPB Amount is the hospital’s average price-standardized, risk-adjusted spending for an MSPB episode. The presentation of the data on the VHHA scorecard is designed to mirror the presentation of the data on the CMS Hospital Compare website.

Data Source: The Centers for Medicare & Medicaid Services


Hospital Guide to Reducing Medicaid Readmissions

Mandated Federal Quality Measures 2012-2015