Lawriter - OAC - 3701-14-04 Performance measures to be reported.

3701-14-04 Performance measures to be reported.

In accordance with rule 3701-14-03 of the Administrative Code, each hospital that is not a children's hospital shall report to the director all of the following measures, and each children's hospital shall report only the infection control measures and the pediatric measures listed in paragraphs (F) and (G) of this rule.

(A) The CMS and the joint commission's measures for acute myocardial infarction, heart failure, pneumonia, the surgical improvement project, and the hospital consumer assessment of healthcare providers and systems listed in appendix A to this rule.

(1) In calculating the appropriateness of care measure for acute myocardial infarction, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, and AMI-8a interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure, but not counted in the numerator of the AMI appropriateness of care measure.

(b) If an eligible patient receives all indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure and once in the numerator of the AMI appropriateness of care measure.

(2) In calculating the appropriateness of care measure for heart failure, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for HF-1, HF-2, HF-3 and HF-4 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure, but not counted in the numerator of the HF appropriateness of care measure.

(b) If an eligible patient receives all indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure and once in the numerator of the HF appropriateness of care measure.

(3) In calculating the appropriateness of care measure for pneumonia, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for PN-2, PN-3, PN-4, PN-5c, PN-6 and PN-7 who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure, but not counted in the numerator of the PN appropriateness of care measure.

(b) If an eligible patient receives all indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure and once in the numerator of the PN appropriateness of care measure.

(4) In calculating the appropriateness of care measure for the surgical care improvement project infection measures, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for SCIP-Inf-1, SCIP-Inf-2, and SCIP-Inf-3 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure, but not counted in the numerator of the SCIP appropriateness of care measure.

(b) If an eligible patient receives all indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure and once in the numerator of the SCIP appropriateness of care measure.

(B) The joint commission's stroke measures listed in appendix A to this rule.

(C) The AHRQ's heart and patient safety measures listed in appendix A to this rule.

(D) The centers for disease control and prevention's surgical site infection event measures listed in appendix A to this rule for the following procedures:

(1) CABG with chest incision only;

(2) Cesarean section; and

(3) Knee prosthesis, initial surgery only.

(E) The centers for disease control and prevention's measures for hospital acquired Clostridium difficile and hospital-acquired methicillin resistant and methicillin susceptible staphylococcus aureus bacteremia listed in appendix A to this rule for patients eighteen years of age or older, using the following reporting options, definitions, and specifications of the CDC's national health care safety network:

(1) The laboratory-identified even option;

(2) The facility-wide reporting option with only one denominator for the entire facility; and

(3) The healthcare facility-onset incident definition to calculate the measure.

(F) The infection control information pertaining to influenza vaccination, using the specifications in appendix B to this rule and the information pertaining to the hospital's hand-washing program and infection control staffing specified in appendix C to this rule.

(G) The following pediatric measures:

(1) The joint commission and NQF endorsed children's asthma care measures for systemic corticosteroids for inpatient asthma and relievers for inpatient asthma (ages two to seventeen) overall rate listed in appendix A to this rule; and

(2) Using the specifications prescribed in appendix D to this rule, the following measures listed in appendix E to this rule for patients less than eighteen years of age:

(a) Prophylactic antibiotic received within one hour prior to surgical incision;

(b) Surgical site infection rates for cardiothoracic, neurosurgical and orthopedic procedures; and

(c) Catheter-associated bloodstream infection rate for ICU patients.

(H) Except as otherwise indicated in paragraph (E) of rule 3701-14-03 of the Administrative Code, the perinatal measures listed in appendix E to this rule:

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Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33, 3727.41
Prior Effective Dates: 1/27/2007, 6/28/09

Prior History: (Effective: 06/28/2009
R.C. 119.032 review dates: 06/01/2014
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33, 3727.41
Prior Effective Dates: 1/27/2007 )