PRMR Hospital Committee

Dear Hospital Committee Member, 

Thank you for attending the PQM Pre-Rulemaking Measure Review (PRMR) Education Meeting. If you haven’t yet, please create a PQM account to access the PRMR Workspace. We are aware of and addressing login and password reset issues raised during the meeting. We also have a Workspace User Guide attached to this email.  

Below is a summary of next steps and participation opportunities. 

Annual risk-adjusted standardized mortality ratio (SMR) of adult inpatients with community-onset sepsis who died during their hospitalization or were discharged to hospice. SMR is reported annually and is calculated by dividing the number of observed community-onset sepsis deaths by the number of predicted community-onset sepsis deaths. 

Percentage of patients aged 18 years and older at the start of the measurement period with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.  

This measure assesses facility level compliance with administration of the CollaboRATE Shared Decision-Making tool to patients undergoing outpatient or ambulatory surgery. To be compliant, facilities must offer 95% of patients the option to complete the CollaboRATE survey within 1 week of the shared decision making conversation.

CollaboRATE has been administered as a paper handout, via mail, electronic mail, computer or web interface, voice recorded telephone interviews, SMS text messages, and through MyChart EHR integration.

Dialysis Facility Discussion of Patient Life Goals is a patient-reported outcome performance measure (the D-PaLS PRO-PM). The D-PaLS PRO-PM is a patient-specific measure that can be used to generate a t-score that is indicative of patient satisfaction with their care team about life goals discussions during the treatment planning and ongoing treatment process. The D-PaLS PRO-PM uses the patient specific scores to generate a performance-based facility level score.

This measure captures the proportion of Emergency Department (ED) visits where patients (all ages, all payers) experienced any one of four quality gaps in access: 

1. The patient waited longer than 60 minutes (1 hour) after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; or 

2. The patient left the ED without being evaluated; or 

Percentage of adult non-ICU hospitalized patients with uncomplicated pneumonia that qualify for 5-day duration according to national guidelines who received excess antibiotic duration, defined as >/= 7 days of total antibiotic therapy including inpatient and discharge antibiotics. Measure is reported annually at the hospital level.

This measure estimates days spent in acute care within 30 days post discharge from an inpatient hospitalization for acute myocardial infarction (AMI). The acute care outcomes include 1) Emergency Department (ED) visits, 2) observation stays (OBSs), and 3) unplanned readmissions. Unplanned readmissions are defined using the planned readmission algorithm (PRA). ED visits are counted as 1 day and OBSs are counted by hours and rounded up to 1 day.

Excess Days in Acute Care (EDAC) After Hospitalization for Diabetes (“Diabetes EDAC measure”) measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for diabetes. This measure is intended to improve the quality of care (with a focus on care transitions) provided to discharged patients who had a diabetes hospitalization by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

This measure estimates days spent in acute care within 30 days post discharge from an inpatient hospitalization for heart failure (HF). The acute care outcomes include 1) Emergency Department (ED) visits, 2) observation stays (OBSs), and 3) unplanned readmissions. Unplanned readmissions are defined using the planned readmission algorithm (PRA). ED visits are counted as 1 day and OBSs are counted by hours and rounded up to 1 day.