COLORADO HOSPITAL

REPORT CARD
________________________________

Implementation Plan of House Bill 06-1278

Prepared by
Colorado Hospital Association
Hospital Report Card Implementation Committee
May 15, 2007
 TABLE OF CONTENTS
COLORADO HOSPITAL REPORT CARD

I. Preamble.............................................................................................................................3
II. Purpose of the Plan ..........................................................................................................3
III. Structure............................................................................................................................ 4
A. Colorado Department of Public Health and Environment (CDPHE)............................ 4
B. Colorado Hospital Association (CHA) ..............................................................................5
C. Hospital Report Card Implementation Committee .........................................................5
D. Performance & Quality Coalition .....................................................................................6
E. Communications Work Group......................................................................................... 6
F. Focus Groups and Consumers ......................................................................................... 6
IV. Process for Selection of Measures ................................................................................ 7
A. Process for Submission of New Measures ...................................................................... 8
B. Process for Inclusion of New Measures...........................................................................9
V. Process for Data Analysis ............................................................................................... 9
VI. Process for Annual Release of Data.............................................................................. 9
VII. Phase I (2007) .................................................................................................................10
A. Implementation Timelines ..............................................................................................10
B. Phase I Measures............................................................................................................... 11
VIII. Phase II..............................................................................................................................13
A. Balanced Scorecard Approach ..........................................................................................13
B. Efficiency of Care.............................................................................................................. 14
C. Hospital-Acquired Infection Measures ............................................................................15
D. Pediatric Measures ............................................................................................................15
IX. Annual Evaluation of Effectiveness .............................................................................16
X. Barriers to Implementation ..........................................................................................16
XI. Continuous Efforts to Improve Care ........................................................................... 17
XII. Appendix .......................................................................................................................... 18
A. Measure Definitions (reported by county) ...................................................................... 18
B. Measure Definitions (reported by individual hospitals) ............................................... 24
C. Hospital Report Card Implementation Committee (current as of 5.15.07)....................31
D. Performance & Quality Coalition (current as of 5.15.07)................................................33
E. List of Common Acronyms............................................................................................. 34
F. Relevant Links for Inclusion on Report Card Website...................................................35

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I. Preamble
The Colorado Hospital Report Card has the primary purpose of ensuring that
statewide hospital data and clinical outcomes are made available to the general
public in a clear and usable manner. The public disclosure of this data will be
made available on an internet website in a manner that not only allows
consumers to conduct an interactive search to compare information from specific
hospitals, but will also provide appropriate guidance on how to use and
understand the data. The Colorado Hospital Report Card will utilize
standardized quality and clinical outcome measures that are endorsed by national
organizations, with established standards to measure the performance of
healthcare providers and hospitals.

II. Purpose of the Plan

A key objective of the Colorado Hospital Report Card is to uphold a statewide
commitment to hospital quality improvement, accountability and transparency.
The purpose of this implementation plan is to provide a framework for the
execution of House Bill 06-1278, created in a collaborative process that includes
the participation of the Colorado Department of Public Health and Environment,
Colorado Hospitals, consumers and other stakeholder organizations. This
framework is inclusive of key elements such as a participation structure, flow of
responsibility, distinct processes for selection of measures, data analysis and data
release, proposed content for the two phases defined in the implementation plan
and a plan for annual review of effectiveness. Although the long term goal of the
report card is for it to be inclusive of measures that are applicable to all
demographics and diverse communities, there are some measures that may not
be appropriate to use for direct comparison of some hospitals given the nature of
the patient population, size of hospital or frequency and number of procedures.
Appropriate consideration for applicable measures will be given to all types of

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 hospitals throughout the state to ensure a process of accountability for hospital
practices and development of quality improvement initiatives for best delivery of
healthcare in Colorado.

III. Structure
The organizational chart and accompanying description of each party defines the
flow of responsibility for the implementation plan of the Colorado Hospital
Report Card.

Colorado Department of Public Health and

Environment

Colorado Hospital
Association

Performance & Quality Hospital Report Card

Coalition Implementation Committee

Communications Work Focus Groups and

Group Consumers

A. Colorado Department of Public Health and Environment (CDPHE)

The Colorado Department of Public Health and Environment (CDPHE) has a
key responsibility to monitor the development and implementation of the
Colorado Hospital Report Card. A CDPHE employee is represented on both
the Performance & Quality Coalition and Hospital Report Card
Implementation Committee. CDPHE and the Colorado Hospital Association
will collaborate on all major processes of the Colorado Hospital Report Card

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 including approving a framework, executing the implementation plan,
monitoring progress and the development of future work.

B. Colorado Hospital Association (CHA)

The Colorado Hospital Association (CHA) has the responsibility of ensuring
that the final plan submitted to CDPHE on or before April 15, 2007 meets all
of the required elements as stipulated by House Bill 06-1278. CHA also is
responsible for ensuring that the final plan is implemented as proposed by
this document.

C. Hospital Report Card Implementation Committee

The Hospital Report Card Implementation Committee is responsible for
identifying and recommending the primary elements of the Colorado Hospital
Report Card, as well as evaluating the overall effectiveness of the report card
and implementation plan on an ongoing basis. The consideration of
measures for the report card will rely on a process using a defined set of
criteria outlined in section I.V. to select measures for inclusion in the
implementation plan as well as for future iterations of the Colorado Hospital
Report Card. The Hospital Report Card Implementation Committee is also
responsible for ensuring that the selection of measures, data analysis and data
release meets the defined processes as outlined in this implementation plan.
The Hospital Report Card Implementation Committee is composed of a broad
membership from the healthcare community including representatives of
hospitals, quality improvement organizations, CDPHE, payers, purchasers
and the business community (see appendix C).

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D. Performance & Quality Coalition
The Performance & Quality Coalition is responsible for facilitating the
development and long term progress of the Colorado Hospital Report Card by
acting in an advisory capacity to the Hospital Report Card Implementation
Committee. The Performance & Quality Coalition is composed of a broad
membership from the healthcare community including representatives of
hospitals, quality improvement organizations, CDPHE, payers, purchasers
and the business community (see appendix D).

E. Communications Work Group

The Communications Work Group is responsible for ensuring that the
Colorado Hospital Report Card is released to targeted audiences. The
Communications Work Group will facilitate the ongoing release of new data
to hospitals and consumer groups and serve as the point of contact for any
media inquiries that pertain to the Colorado Hospital Report Card. This work
group will ensure that the general public and other audiences have knowledge
of comparative hospital quality information and that this information is in a
functional format such that it is understandable and usable.

F. Focus Groups and Consumers

Various focus groups will be organized by the CHA Communications Director
in coordination with CDPHE and the Communications Work Group to solicit
feedback on the website design and overall usability of the Colorado Hospital
Report Card. Focus groups will be surveyed prior to the first official data
release as well as on a continued basis to evaluate the ongoing effectiveness of
the report card. Current suggested focus groups include: consumers,
hospitals, physicians, purchasers and media. Particular focus will be placed

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 on surveying consumers as they are the targeted population for the utilization
of the report card.

IV. Process for Selection of Measures

The consideration and selection of measures for inclusion in the Colorado
Hospital Report Card will be defined by a rigorous process to ensure consistency
and continued applicability. The consideration and selection of new or modified
measures will be an ongoing process. The flow of consideration and subsequent
approval for new or modified measures is defined below:

Colorado Department of Public Health and Environment

Final approval authority of new or modified measures

Colorado Hospital Association Board

Endorses measure selection for presentation to CDPHE

Performance & Quality Coalition Hospital Report Card Implementation Committee

Acts in an advisory capacity for selection of new measures Recommends measures based on defined criteria

As a general rule, only measures that have met certain criteria will be considered
for inclusion in the Colorado Hospital Report Card. This criteria has been
defined by quality improvement experts and other related professionals to ensure
that the Colorado Hospital Report Card meets the objectives and goals set forth by
the implementation plan.

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The defined criteria established by the Hospital Report Card Implementation
Committee include:
• The collection of data and definition of measures must be consistent and
unambiguous across all Colorado hospitals.
• The measures and accompanying definition must be understandable and
usable to the public.
• The measures must be reliable (consistent) and valid (precise, logical).
• The measures must have statistical significance when used for
comparison of hospitals.
• The measures must be actionable by hospitals and/or medical staff.
• The measures must be endorsed by quality standard groups (e.g. National
Quality Forum, National Association of Children’s Hospitals and Related
Institutions).
• The measures must be applicable to current public health and healthcare
goals for quality improvement.

All parties defined in the flow chart have a responsibility of ensuring that both
the selection criteria and current designated measures meet the changing
needs of consumers and are applicable to the current needs and concerns of
public health.

A. Process for Submission of New Measures

Interested parties will have an opportunity to propose measures for possible
inclusion in the Colorado Hospital Report Card. Requests for consideration
may be submitted to the Hospital Report Card Implementation Committee
provided that they are inclusive of a brief explanation of the proposed measure
and a short justification for the purpose and need of such an inclusion. A list

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 of all proposed measures will be maintained and included in an annual report
to CDPHE.

B. Process for Inclusion of New Measures

New measures will be considered for inclusion in the Colorado Hospital
Report Card by the Hospital Report Card Implementation Committee on an
ongoing basis. The Hospital Report Card Implementation Committee will
evaluate proposed measures based on the criteria outlined in section I.V. The
Implementation Committee will also utilize the recommendations of quality
improvement experts and other stakeholder entities. Recommendations for
new or modified measures will be shared with the Performance & Quality
Coalition for review and comment. Selected measures by the Hospital Report
Card Implementation Committee will then be presented to the CHA Board for
review and endorsement. The final approval authority of new or modified
measures rests with CDPHE.

V. Process for Data Analysis

Data that specifically pertains to measures selected for inclusion in the Colorado
Hospital Report Card will be collected from all Colorado hospitals on an annual
basis. Data from the most recent three year period will be collected and analyzed
by CHA. The integrity of the data will be evaluated prior to the official release on
the public website. Statewide or other geographic trends will also be evaluated as
part of the data analysis. Valid trends that are identified will be shared with
hospitals in an effort to facilitate improvement in specific areas of healthcare.

VI. Process for Annual Release of Data

The annual release of data to the general public will be facilitated by the CHA
Communications Director and Communications Work Group. It is essential that

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 the process of releasing annual data is such that it ensures that this information is
easily accessible, readily available and widely publicized. The release of annual
data to all Colorado hospitals will occur prior to the official release of data and
results to the public as stipulated by House Bill 06-1278. This data will be given
to all Colorado hospitals one month prior to the public release to provide an
opportunity for thorough review and comment from all hospitals.

VII. Phase I (2007)

A. Implementation Timelines
• April 15, 2007
ƒ Submit a plan to the executive director of CDPHE and report on the
status of implementation of House Bill 06-1278.
• May 1, 2007
ƒ Begin the detailed development of the website.
ƒ Initiate the communications plan.
• May 15, 2007
ƒ Submit a final plan and report on the status of implementation to
the Governor, the President of the Senate and the Speaker of the
House of Representatives.
ƒ Provide copies of the implementation plan to all members of the
general assembly and made the plan available to the public on an
internet website.
• June 2007 – September 2007
ƒ Engage focus groups and stakeholders.
• September 15, 2007
ƒ Make the Colorado Hospital Report Card available to every hospital
in the state to ensure that each hospital has the opportunity to
evaluate the data and submit comments.

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 • October 15, 2007
ƒ Submit the Colorado Hospital Report Card plan to the executive
director of CDPHE for approval of the public disclosure of data.
• November 30, 2007
ƒ Publish the Colorado Hospital Report Card to the general public as
stipulated by House Bill 06-1278.

B. Phase I Measures
Data that will be used in the Colorado Hospital Report Card is collected and
compiled by the Colorado Hospital Association on an ongoing basis from all
acute care hospitals in Colorado. Phase I of the Hospital Report Card will be
inclusive of data from 2004, 2005 and 2006.

1. Agency for Healthcare Research and Quality (AHRQ) Risk-Adjusted

Mortality Rate Quality Measures
a. Condition Measures
• Acute Myocardial Infarction (AMI)
• Congestive Heart Failure (CHF)
• Gastrointestinal Hemorrhage (GI bleed)
• Hip Fracture
• Pneumonia
• Stroke
b. Procedure Measures
• Carotid Endarterectomy (CEA)
• Coronary Artery Bypass Graft (CABG)
• Craniotomy
• Hip Replacement
• Percutaneous Transluminal Coronary Angioplasty (PTCA)

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2. AHRQ Volume Measures
• Abdominal Aortic Aneurysm Repair (AAA)
• Carotid Endarterectomy (CEA)
• Coronary Artery Bypass Graft (CABG)
• Percutaneous Transluminal Coronary Angioplasty (PTCA)

3. AHRQ Prevention Quality Measures

a. These prevention quality measures represent hospital admission
rates (by patient’s county of residence) for the following ambulatory
care-sensitive conditions:
• Amputations, lower extremity, diabetic patients
• Angina, without procedure
• Appendicitis, perforated
• Asthma, adult
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Dehydration
• Diabetes, long-term complications
• Diabetes, short-term complications
• Diabetes, uncontrolled
• Hypertension
• Low Birth Weight
• Pneumonia
• Urinary Tract Infections (UTI)

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 4. Other Quality Measures
a. AHRQ Patient Safety Measures
• Decubitus Ulcer Rate
• Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
Rate, postoperative
• Sepsis Rate, postoperative
b. Hospital-Acquired Infection Measures
c. Pediatric Measures

VIII. Phase II
A. Balanced Scorecard Approach
The long term goal for the Colorado Hospital Report Card is for it to be
comprised of a comprehensive set of measures that address various aspects of
quality improvement. The Hospital Report Card Implementation Committee
has identified possible areas of focus for the next phase of the report card,
however other areas that have not yet been identified in this implementation
plan can be considered for inclusion in future iterations of the report card
provided they meet the criteria outlined in section I.V. and speak to the
balanced scorecard approach of this implementation plan.

1. Clinical Quality
• AHRQ Quality Measures
• AHRQ Prevention Measures
2. Patient Safety
• AHRQ Patient Safety Measures
• Hospital-Acquired Infection Measures (as reported by Colorado
hospitals)

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 3. Patient Satisfaction
• U.S. Department of Health and Human Services (HHS) Hospital
Consumer Assessment of Health Providers and Systems Survey
(HCAHPS) Measures
4. Best Practices
• Centers for Medicare & Medicaid Services (CMS) Core Measures /
HHS Hospital Compare
• IHI 100,000 Lives Campaign
• IHI 5 Million Lives Campaign
5. Efficiency of Care

B. Efficiency of Care
As it pertains to the Colorado Hospital Report Card, efficiency of care will be
defined as a measure of quality of care in combination with healthcare
resource use. Currently, measures that are used to evaluate efficiency rely on
proxies for measuring efficiency and costs of care such as hospital charges and
average length of stay. It has not been demonstrated that these proxies
accurately reflect resource use, especially given the consideration of various
confounders that may influence outcomes.

The Hospital Report Card Implementation Committee and CDPHE will

evaluate emerging efficiency and cost measures as they are developed. Many
organizations, including AHRQ, CHA and the Colorado Foundation for
Medical Care (CFMC), are conducting research to examine potential cost
measures including cost to charge ratios, hospital payment rates and hospital
readmission rates. Validated efficiency and cost measures will be considered
for inclusion in the Colorado Hospital Report Card as they are developed and
may be included in future iterations of the report card provided that they meet

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 the defined selection criteria set forth in section I.V. and have been endorsed
by recognized quality standard groups as valid and reliable measures.

C. Hospital-Acquired Infection Measures

Hospital-acquired infection rates are important measures for inclusion on the
Colorado Hospital Report Card. Legislation was recently passed in Colorado
that mandates reporting of hospital-acquired infections to the Centers for
Disease Control and CDPHE. An infection advisory committee has been
appointed and will meet on a regular basis to determine which infection rates
will be reported for certain medical procedures. Although a separate report
will be generated by the Health Facility-Acquired Infection Advisory
Committee, it is the goal of the Colorado Hospital Report Card to have these
infection measures included in the report card and disseminated in a manner
that is meaningful to the public. Hospital-acquired infection measures will be
included in future iterations of the report card as they become available
through CDPHE.

D. Pediatric Measures
Current pediatric quality measures, such as those published by AHRQ, have a
significant risk of misinforming the public since these measures are mostly
an assessment of rare events. The incidence rate of rare event measures have
the potential to be aversely biased in institutions caring for high-risk
individuals, which may result in unintentional misinformation to the general
public about health quality measures in these specific hospitals.

The Hospital Report Card Implementation Committee and CDPHE will

consider new pediatric quality measures as they are developed and validated.
Pediatric quality measures that successfully detect bias and are designed to

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 appropriately adjust risk will be considered for inclusion in the Colorado
Hospital Report Card on an annual basis provided they meet the defined
criteria set forth in section I.V. and are recognized by quality standard groups
as valid and reliable measures.

IX. Annual Evaluation of Effectiveness

The Hospital Report Card Implementation Committee is responsible for the
ongoing evaluation of the Colorado Hospital Report Card. This committee will
establish a formal process for an annual review of the Colorado Hospital Report
Card and implementation plan. The annual review will largely involve evaluating
the ongoing effectiveness of the Colorado Hospital Report Card as well as the
implementation plan to ensure that the established elements adequately address
the long term goal of the report card. The assessment of the Colorado Hospital
Report Card will involve the review of quality improvement measures and
evaluation of the public website used for reporting the data. New measures will
be considered and selected for inclusion to meet the changing needs of the
consumers and current included measures will be reviewed to ensure their
ongoing applicability. The website will also be assessed annually for consumer
usability. Focus groups will be engaged on a regular basis to facilitate this process
and provide outside perspective and opinion. Lastly, potential barriers for best
implementation of the Colorado Hospital Report Card will be assessed regularly
by the Implementation Committee. Annual reports will be submitted to CDPHE.

X. Barriers to Implementation
At the time of presentation of the implementation plan to the Governor, the
President of the Senate and the Speaker of the House of Representatives, the
Hospital Report Card Implementation Committee has not identified any barriers
that may hinder the implementation of House Bill 06-1278.

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XI. Continuous Efforts to Improve Care
CDPHE and CHA are committed to the continuous improvement of healthcare
quality and patient safety improvements. CDPHE and CHA will continue to
collaborate with various outside entities to ensure that new quality improvement
efforts and best practice opportunities are reviewed on an annual basis.

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XII. Appendix
A. Measure Definitions (reported by county)
1. Amputation Admission Rate, lower extremity, diabetic patients
(AHRQ Prevention Quality Measure)

• Description - Diabetes is a major risk factor for lower-extremity

amputation, which can be caused by infection, neuropathy and
microvascular disease.

• Rate Calculation - Calculated as number of admissions for lower-

extremity amputation among patients with diabetes per 100,000
population.

• Justification - Proper and continued treatment and glucose control may

reduce the incidence of lower-extremity amputation and lower rates
represent better quality care.

2. Angina Admission Rate, without procedure

(AHRQ Prevention Quality Measure)

• Description - Most heart attacks involve discomfort in the center of the

chest that lasts for more than a few minutes or goes away and comes
back. This discomfort, known as angina, can feel like uncomfortable
pressure, squeezing, fullness or pain. Both stable and unstable angina
are symptoms of potential coronary artery disease. Effective
management of coronary disease reduces the occurrence of major
cardiac events such as heart attacks and may also reduce admission
rates for angina.

• Rate Calculation - Calculated as number of admissions for angina

without procedure per 100,000 population.

• Justification - Proper outpatient treatment may reduce admissions for

angina (without procedure) and lower rates represent better quality
care.

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3. Appendicitis Admission Rate, perforated
(AHRQ Prevention Quality Measure)

• Description - Perforated appendix may occur when appropriate

treatment for acute appendicitis is delayed for a number of reasons,
including problems with access to care, failure by the patient to
interpret symptoms as important, misdiagnosis and other delays in
obtaining surgery.

• Rate Calculation - Calculated as the number of admissions for

perforated appendix as a share of all admissions for appendicitis within
an area.

• Justification - Timely diagnosis and treatment may reduce the

incidence of perforated appendix and lower rates represent better
quality care.

4. Asthma Admission Rate, adult

(AHRQ Prevention Quality Measure)

• Definition - Asthma is a disease that affects the lungs. It causes

repeated episodes of wheezing, breathlessness, chest tightness and
nighttime or early morning coughing. Asthma is one of the most
common reasons for hospital admission and emergency room care.

• Rate Calculation - Calculated as number of admissions for asthma in

adults per 100,000 population.

• Justification - Proper outpatient treatment may reduce the incidence

or exacerbation of asthma requiring hospitalization and lower rates
represent better quality care.

5. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate

(AHRQ Prevention Quality Measure)

• Definition - Chronic obstructive pulmonary disease (COPD) comprises

three primary diseases that cause respiratory dysfunction - asthma,
emphysema, and chronic bronchitis - each with distinct etiologies,
treatments and outcomes. This measure examines emphysema and
bronchitis only; asthma is discussed separately.

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 • Rate Calculation - Calculated as number of admissions for COPD per
100,000 population.

• Justification - Proper outpatient treatment may reduce admissions for

COPD and lower rates represent better quality care.

6. Congestive Heart Failure (CHF) Admission Rate

(AHRQ Prevention Quality Measure)

• Description - Congestive heart failure (CHF) can be controlled in an

outpatient setting for the most part; however, the disease is a chronic
progressive disorder for which some hospitalizations are appropriate.

• Rate Calculation - Calculated as number of admissions for CHF per

100,000 population.

• Justification - Proper outpatient treatment may reduce admissions

for CHF and lower rates represent better quality care.

7. Dehydration Admission Rate

(AHRQ Prevention Quality Measure)

• Description - Dehydration is a serious acute condition that occurs in

frail patients and patients with other underlying illnesses following
insufficient attention and support for fluid intake.

• Rate Calculation - Calculated as number of admissions for dehydration

per 100,000 population.

• Justification - Proper outpatient treatment may reduce admissions for

dehydration and lower rates represent better quality care.

8. Diabetes Admission Rate, long-term complications

(AHRQ Prevention Quality Measure)

• Description - Long-term complications of diabetes mellitus include

renal, eye, neurological and circulatory disorders. Long term
complications occur at some time in the majority of patients with
diabetes to some degree. Diabetes can be associated with serious
complications and premature death.

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 • Rate Calculation - Calculated as number of admissions for diabetes
(long term complications) per 100,000 population.

• Justification - Proper outpatient treatment and adherence to prescribed

care may reduce the incidence of diabetic long term complications and
lower rates represent better quality care.

9. Diabetes Admission Rate, short-term complications

(AHRQ Prevention Quality Measure)

• Description - Short term complications of diabetes mellitus include

diabetic ketoacidosis, hyperosmolarity and coma. These life-
threatening emergencies arise when a patient experiences an excess of
glucose (hyperglycemia) or insulin (hypoglycemia).

• Rate Calculation - Calculated as number of admissions for diabetes

(short term complications) per 100,000 population.

• Justification - Proper outpatient treatment and adherence to prescribed

care may reduce the incidence of diabetic short term complications and
lower rates represent better quality care.

10. Diabetes Admission Rate, uncontrolled

(AHRQ Prevention Quality Measure)

• Description - Uncontrolled diabetes should be used in conjunction

with short term complications of diabetes, which include diabetic
ketoacidosis, hyperosmolarity and coma.

• Rate Calculation - Calculated as number of admissions for

uncontrolled diabetes per 100,000 population.

• Justification - Proper outpatient treatment and adherence to prescribed

care may reduce the incidence of uncontrolled diabetes and lower rates
represent better quality care.

11. Hypertension Admission Rate

(AHRQ Prevention Quality Measure)

• Description - Hypertension is a chronic condition that is often

controllable in an outpatient setting with appropriate use of drug
therapy. Hypertension, also known as high blood pressure, is a

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 medical condition in which there is narrowed room in the arteries,
thereby causing difficulty in blood flow. The complications associated
with hypertension increase the risk of heart attack, heart failure, stroke
and kidney failure.

• Rate Calculation - Calculated as number of admissions for

hypertension in adults per 100,000 population.

• Justification - Proper outpatient treatment may reduce admissions for

hypertension and lower rates represent better quality care.

12. Low Birth Weight Admission Rate

(AHRQ Prevention Quality Measure)

• Description - Low birth weight infants are classified as those infants

born weighing 5 pounds, 8 ounces or less (under 2,500 grams). Low
birth weight is a significant health problem, contributing to infant
mortality and long term developmental problems.

• Rate Calculation - Calculated as the number of low birth weights as a

share of all births in an area.

• Justification - Proper preventive care may reduce incidence of low birth

weight and lower rates represent better quality care.

13. Pneumonia Admission Rate, Bacterial

(AHRQ Prevention Quality Measure)

• Description - Bacterial pneumonia is a relatively common acute

condition, treatable for the most part with antibiotics. If left untreated
in susceptible individuals, such as the elderly, pneumonia can lead to
death.

• Rate Calculation - Calculated as number of admissions for bacterial

pneumonia per 100,000 population.

• Justification - Proper outpatient treatment may reduce admissions

for bacterial pneumonia in non-susceptible individuals and lower
rates represent better quality care.

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14. Urinary Tract Infection (UTI) Admission Rate
(AHRQ Prevention Quality Measure)

• Description - Urinary tract infection is a common acute condition that

can, for the most part, be treated with antibiotics in an outpatient
setting. However, this condition can progress to more clinically
significant infections, such as pyelonephritis, in vulnerable individuals
with inadequate treatment.

• Rate Calculation - Calculated as number of admissions for urinary

infection per 100,000 population.

• Justification - Proper outpatient treatment may reduce admissions for

urinary infection and lower rates represent better quality care.

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B. Measure Definitions (reported by individual hospitals)

1. Abdominal Aortic Aneurysm Repair (AAA)

(AHRQ Volume Measure)

• Description - Abdominal aortic aneurysm (AAA) repair is a relatively

rare procedure that requires proficiency with the use of complex
equipment; technical errors may lead to clinically significant
complications, such as arrhythmias, acute myocardial infarction,
colonic ischemia and death.

• Volume Calculation - Raw volume of provider-level AAA repair.

• Justification - Higher volumes have been associated with better

outcomes which represent better quality.

2. Acute Myocardial Infarction (AMI)

(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - An acute myocardial infarction (heart attack) can

result when blood supply to the heart muscle is cut off. Cells in the
heart muscle do not receive enough oxygen and begin to die. The
more time that passes without treatment to restore blood flow, the
greater the damage to the heart.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for AMI.

• Justification - Timely and effective treatments for acute myocardial

infarction (AMI), which are essential for patient survival, include
appropriate use of thrombolytic therapy and revascularization.

3. Carotid Endarterectomy (CEA)

(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

• Definition - Carotid endarterectomy is a surgical procedure that

removes fatty buildup of plaque from the carotid artery. This
procedure has been widely used as a way to reduce stroke risk.

• Rate Calculation - Calculated as number of deaths per 100 CEAs

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 • Justification - Carotid endarterectomy (CEA) is a fairly common
procedure that requires proficiency with the use of complex
equipment; technical errors may lead to clinically significant
complications, such as abrupt carotid occlusion with or without
stroke, myocardial infarction and death.

4. Carotid Endarterectomy (CEA)

(AHRQ Volume Measure)

• Definition - See CEA Risk-Adjusted Mortality Rate, Procedure Measure

• Volume Calculation - Raw volume of provider-level CEA

• Justification - Higher volumes have been associated with better

outcomes, which represent better quality.

5. Congestive Heart Failure (CHF)

(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - Congestive heart failure (CHF), or heart failure, is a

condition in which the heart cannot pump enough blood to the
body's other organs. As blood flow out of the heart slows, blood
returning to the heart through the veins backs up, causing
congestion in the tissues. Swelling (edema) often results.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for CHF.

• Justification - Congestive heart failure (CHF) is a progressive,

chronic disease with substantial short term mortality, which varies
from provider to provider.

6. Coronary Artery Bypass Graft (CABG)

(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

• Description - This procedure treats blocked heart arteries by creating

new passages for blood to flow to your heart muscle. It works by taking
arteries or veins from other parts of your body, called grafts, and using
them to reroute the blood around the clogged artery.

• Rate Calculation - Calculated as number of deaths per 100 CABG

procedures

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 • Justification - Coronary artery bypass graft (CABG) requires proficiency
with the use of complex equipment; technical errors may lead to
clinically significant complications, such as myocardial infarction,
stroke and death.

7. Coronary Artery Bypass Graft (CABG)

(AHRQ Volume Measure)

• Definition - See CABG Risk-Adjusted Mortality Rate, Procedure

Measure

• Volume Calculation - Raw volume of provider-level CABG.

• Justification - Higher volumes have been associated with better

outcomes, which represent better quality.

8. Craniotomy Mortality
(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

• Description - A craniotomy is an operation, or surgery, on the brain.

The surgeon makes an opening in the skull so that a brain
operation can be performed. A craniotomy may be done in any area
of the skull and may be almost any size.

• Rate Calculation - Calculated as number of deaths per 100

craniotomies

• Justification - Craniotomy for the treatment of subarachnoid

hemorrhage or cerebral aneurysm entails substantially high post-
operative mortality rates.

9. Decubitus Ulcer Rate

(AHRQ Patient Safety Measure)

• Description - A decubitus ulcer, also called a pressure ulcer, is an area

of skin that breaks down when one position is held for too long without
weight shiftment. This can occur in individuals that use wheelchairs or
are bedridden, even for a short period of time (for example, after
surgery or an injury). The constant pressure against the skin reduces
the blood supply to that area and the affected tissue dies.

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 • Rate Calculation - Decubitus ulcer rate is calculated using cases of
decubitus ulcer per 1,000 discharges with a length of stay of four or
more days.

• Justification - A decubitus ulcer starts as reddened skin but can get

progressively worse, forming a blister, then an open sore, and finally a
crater. Damage can occur to tissues below the skin such as muscle,
tendon, joint and bone.

10. Deep Vein Thrombosis (DVT) Rate, postoperative

(AHRQ Patient Safety Measure)

• Description - Deep vein thrombosis (DVT) refers to the formation of a

thrombus (blood clot) within a deep vein, commonly in the thigh or
calf.

• Rate Calculation - Deep vein thrombosis rate is calculated as cases of

DVT per 1000 surgical discharges with an operating room procedure.

• Justification - If the thrombus partially or completely blocks the flow of

blood through the vein, blood begins to pool and build-up below the
site, likely causing chronic swelling and pain. A thrombus can also
break free and travel through the veins reaching the lungs. Once in the
lungs it is called a pulmonary embolism (PE), which is a potentially
fatal condition that can kill within hours.

11. Gastrointestinal Hemorrhage (GI bleed)

(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - Gastrointestinal bleeding refers to any bleeding that

starts in the gastrointestinal tract, which extends from the mouth to
the large bowel. The degree of bleeding can range from nearly
undetectable to acute, massive and life-threatening.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for GI hemorrhage.

• Justification - Gastrointestinal (GI) hemorrhage may lead to death

when uncontrolled; the ability to manage severely ill patients with
comorbidities may influence the mortality rate.

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12. Hip Fracture
(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - If more pressure is put on a bone than it can stand, it

will split or break. A break of any size is called a fracture.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for hip fracture.

• Justification - Hip fractures, which are a common cause of

morbidity and functional decline among elderly persons, are
associated with a significant increase in the subsequent risk of
mortality.

13. Hip Replacement

(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

• Description - Total hip arthroplasty (without hip fracture) is an

elective procedure performed to improve function and relieve pain
among patients with chronic osteoarthritis, rheumatoid arthritis, or
other degenerative processes involving the hip joint.

• Rate Calculation - Calculated as number of deaths per 100 hip

replacements.

• Justification - Better processes of care may reduce mortality for hip

replacement, which represents better quality care.

14. Percutaneous Transluminal Coronary Angioplasty (PTCA)

(AHRQ Risk-Adjusted Mortality Rate, Procedure Measure)

• Description - Percutaneous transluminal coronary angioplasty

(PTCA) is performed on patients with coronary artery disease.
PTCA involves threading a catheter (or balloon-tipped tube) from an
artery in the groin to a trouble spot in an artery of the heart. The
balloon is inflated so that the narrowed coronary artery can widen
and allow blood to flow more easily. No ideal rate for PTCA has
been established.

• Rate Calculation - Calculated as the number of deaths per 100

PTCAs

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 • Justification - Percutaneous transluminal coronary angioplasty
(PTCA) is a relatively common procedure that requires proficiency
with the use of complex equipment; technical errors may lead to
clinically significant complications.

15. Percutaneous Transluminal Coronary Angioplasty (PTCA)

(AHRQ Volume Measure)

• Description - See PTCA Risk-Adjusted Mortality Rate, Procedure

Measure

• Volume Calculation - Raw volume of PTCA.

• Justification - Higher volumes have been associated with better

outcomes, which represent better quality.

16. Pneumonia
(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - Invasive disease caused by Streptococcus pneumoniae

(pneumococcus) frequently manifests as bacteremia (bloodstream
infections), pneumonia or meningitis. Antibiotic resistance has
become an increasing problem among isolates of S. pneumoniae.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for pneumonia.

• Justification - Treatment with appropriate antibiotics may reduce

mortality from pneumonia, which is a leading cause of death in the
United States.

17. Pneumonia Infection Rate, ventilator-associated

(IHI Measure)

• Description - Ventilator-associated pneumonia (VAP) is defined as

nosocomial pneumonia in a patient on mechanical ventilator support
(by endotracheal tube or tracheostomy) for greater than or equal to 48
hours.

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18. Pulmonary Embolism (PE) Rate, postoperative
(AHRQ Patient Safety Measure)

• Definition - A pulmonary embolus (PE) is a blockage of an artery in the

lungs caused by fat, air, clumped tumor cells or a blood clot.

• Rate Calculation - Pulmonary embolism rate is calculated as cases of

PE per 1000 surgical discharges with an operating room procedure.

• Justification - Pulmonary embolus can cause severe injury or even

death.

19. Sepsis Rate, postoperative

(AHRQ Patient Safety Measure)

• Definition - Sepsis is a severe illness caused by overwhelming infection

of the bloodstream by toxin-producing bacteria.

• Rate Calculation - Sepsis rate is calculated as cases of sepsis per 1000

elective surgery patients with an operating room procedure and a
length of stay of four days or more.

• Justification - Sepsis is often life-threatening, especially in people with

a weakened immune system or other medical illnesses.

20. Stroke
(AHRQ Risk-Adjusted Mortality Rate, Condition Measure)

• Description - A stroke can occur when the blood supply to part of

the brain is blocked or when a blood vessel in the brain bursts,
causing damage to a part of the brain.

• Rate Calculation - Calculated as the number of deaths per 100

discharges for stroke.

• Justification - Quality treatment for acute stroke must be timely and

efficient to prevent potentially fatal brain tissue death, and patients
may not present until after the fragile window of time has passed.

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C. Hospital Report Card Implementation Committee (current as of 5.15.07)
• Donna Kusuda (chair)
VP, Quality Improvement & Patient Safety
HCA/HealthONE

• Scott Anderson
Vice President of Professional Activities
Colorado Hospital Association

• Crystal Berumen
Project Director, Patient Safety Initiatives
Colorado Hospital Association

• Lisa Camplese
VP, Clinical Quality and Care Coordination
Centura Health

• Cathy Dill
Director of Quality Management
Estes Park Medical Center

• Gail Finley-Rarey
Chief of Acute, Primary, Community-based Service and Occurrence
Reporting Section, Health Facilities and EMS Division
Colorado Department of Public Health and Environment

• Teresa Fisher
Patient Safety Specialist
The Children’s Hospital

• Donna Marshall
Executive Director
Colorado Business Group on Health

• Elaine Massie
Director of Quality Improvement / Risk Management
Platte Valley Medical Center

• Kendra Moldenhauer
Manager, Patient Safety and Quality
Denver Health

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• Janet Pogar
Director of Contracting
Anthem Blue Cross

• Danielle Seymour
Quality Decision Support
Exempla Healthcare

• Judy Sikes
Director of Accreditation / Medical Staff Services
Parkview Medical Center

• Kristin Stocker
Coordinator of Regulatory Affairs
University of Colorado Hospital

• Mack Thomas
Director, Performance Management
Centura Health

• Debbie Welle-Powell
Vice President, Payer Strategies & Legislative Affairs
Exempla Healthcare

• Judy Zuccone
Director of Quality Services
Yampa Valley Medical Center

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D. Performance & Quality Coalition (current as of 5.15.07)
• Anthem Blue Cross
• Banner Health
• Colorado Department of Public Health and Environment
• COPIC Insurance
• Centers for Medicare and Medicaid Services
• Centura Health
• Colorado Association of Health Plans
• Colorado Business Group on Health
• Colorado Foundation for Medical Care
• Colorado Health Institute
• Colorado Hospital Association
• Colorado Medical Society
• Exempla Healthcare
• HCA/HealthONE
• Physician Health Partners
• Platte Valley Medical Center
• United Healthcare
• University of Colorado Hospital

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E. List of Common Acronyms
• AHRQ, Agency for Healthcare Research and Quality
• CDPHE, Colorado Department of Public Health and Environment
• CHA, Colorado Hospital Association
• CMS, Centers for Medicare and Medicaid Services
• HCAHPS, Hospital Consumer Assessment of Health Providers and
Systems Survey
• HHS, U.S. Department of Health and Human Services
• IHI, Institute for Healthcare Improvement

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F. Relevant Links for Inclusion on Report Card Website
• Agency for Healthcare Research and Quality (AHRQ),
www.qualitymeasures.ahrq.gov
• Centers for Disease Control (CDC), www.cdc.gov
• Centers for Medicaid and Medicare (CMS), www.cms.hhs.gov
• Institute for Healthcare Improvement (IHI), www.ihi.org
• The Joint Commission (JCAHO), www.jointcommission.org

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