FY 2011 Update

from the CMS Annual Update:

CMS is adding 4 new measures for the FY 2011 program, and retiring one existing measure. For some of these new measures, the hospitals will not have to affirmatively report data to CMS. Instead, CMS will calculate the measures using Medicare claims data. The total number of measures that are included in the FY 2011 payment update is 46.

The inclusion of these additional measures will encourage hospitals to take steps to make care safer for patients. Heart failure, pneumonia, and heart attack – three conditions that are included in the 46 measures for FY 2011 – rank among the ten most common diagnoses for Medicare inpatient care, and therefore have the greatest impacts on costs to the Medicare program. The processes of care represented by quality measures for these three conditions are known to improve the quality of care patients receive during inpatient visits to the hospital.

In addition, the measures for the FY 2011 payment determination will include a measure to track re-admissions for heart failure.

The 4 new measures are:

A. Surgical Care Improvement Project (SCIP) Measure

  • SCIP Infection 9, peri-operative urinary catheter removal on post operative day 1 or 2
  • SCIP Infection 10, peri-operative temperature management

B. Stroke Care Measure

  • Participation in a systematic clinical database registry for stroke care

C. Nursing Sensitive Care Measure:

  • Participation in a systematic clinical database registry for nursing sensitive care


  • Heart Attack (Acute Myocardial Infarction)
  • Aspirin at arrival
  • Aspirin prescribed at discharge
  • ACE inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction
  • Beta blocker at arrival
  • Beta blocker prescribed at discharge
  • Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival
  • Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)
  • Adult smoking cessation advice/counseling
  • Heart Failure (HF)
  • Left ventricular function assessment
  • ACE inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction
  • Discharge instructions
  • Adult smoking cessation advice/counseling
  • Pneumonia (PNE)
  • Timing of receipt of initial antibiotic following hospital arrival
  • Pneumococcal vaccination status
  • Blood culture performed before first antibiotic received in hospital
  • Adult smoking cessation advice/counseling
  • Appropriate initial antibiotic selection
  • Influenza vaccination status
  • Surgical Care Improvement Project (SCIP) ?20(Previously SIP)
  • Prophylactic antibiotic received within 1 hour prior to surgical incision
  • Prophylactic antibiotics discontinued within 24 hours after surgery end time
  • SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients
  • SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery
  • SCIP Infection 2: Prophylactic antibiotic selection for surgical patients
  • SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
  • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal
  • Mortality Measures
  • Acute Myocardial Infarction 30-day mortality ?28Medicare patients)
  • Heart Failure 30-day mortality (­Medicare patients)
  • Pneumonia 30-day mortality (Medicare patients)
  • Heart failure (HF) 30 day risk standardized re-admission measure (Medicare patients)
  • B. AHRQ PSI and Nursing Sensitive Care Measure:
  • Death among surgical patients with treatable serious complications
  • AHRQ Patient Safety and Inpatient Quality Indicator Measures
  • Patient Safety Indicators (PSIs)
  • Iatrogenic pneumothorax, adult
  • Postoperative wound dehiscence
  • Accidental puncture or laceration
  • Inpatient Quality Indicator Measures
  • Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)
  • Hip fracture mortality rate
  • Mortality for selected medical conditions (composite)
  • Mortality for selected surgical procedures (composite)
  • Complication/patient safety for selected indicators (composite)
  • Cardiac Surgery Measure:
  • Participation in a systematic database for cardiac surgery
  • Patients’ Experience of Care
  • HCAHPS Patient Survey


CMS Fact Sheet on this topic is found here.

Reporting Hospital Quality for Annual Payment Update DRASection 5001(a)  MMASection 501(b)

For the CMS page detailing this issue click here.

CMS Hospital Inpatient Quality Reporting Program

CMS Hospital Compare



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