IQI SFY2016 Specifications Manual Updates – 3Q2015 Discharges Revised 06/24/2015 Removal of SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge

Table of Contents  New Data Elements:  Alcohol Use Status  Brief Intervention

Table of Contents  Removed Data Elements  Arrival Date  Arrival Time  Cognitive Impairment  Data element was removed and has been integrated into the Tobacco Use Status and Alcohol Use Status data elements  Delivery Date  Delivery Time

Criteria  Performance Measures  OBS 4: Early Elective Delivery  OBS 5: Exclusive Breast Milk Feeding  OBS 6: Cesarean Section: Nulliparous Women  TOB 1: Tobacco Use Screening  TOB 2: Tobacco Use Treatment Provided or Offered  TOB 3: Tobacco Use Treatment Provided or Offered at Discharge  NBS 1: Timely Collection of Newborn Screening Specimen  NBS 2: Timely Submission of Newborn Screening Specimen to the AR Department of Health Public Health Laboratory  Submission Measures  SUB 1: Alcohol Use Screening  SUB 2: Alcohol Use Brief Intervention Provided or Offered  Outcome Measures  OP 10: Abdomen CT – Use of Contrast Material

Measure Information Form  OBS 4: Elective Delivery  Numerator Statement  Included Populations  Cesarean section as defined in Appendix A, Table and all of the following: not in Labor, no history of a Prior Uterine Surgery  Denominator Statement  Excluded Populations  Gestation Age <37 Weeks or UTD  Data Elements  Prior Uterine Surgery  Updated Algorithm

Measure Information Form  OBS 5: Exclusive Breast Milk Feeding  No Changes  OBS 6: Cesarean Section: Nulliparous Women  Denominator Statement  Excluded Populations  Gestation age <37 Weeks or UTD  Updated Algorithm  NBS 1: Timely Collection of Newborn Screening Specimen  No Changes  NBS 2: Timely Submission of Newborn Screening Specimen to the AR Department of Health Public Health Laboratory  No Changes

Measure Information Form  TOB 1: Tobacco Use Screening  Denominator Statement  Excluded Populations  Patients less than 18 years of age  Data Elements  Tobacco Use Status  Updated Algorithm  TOB 2: Tobacco Use Treatment Provided or Offered  Data Elements  Comfort Measures Only  Updated Algorithm  TOB 3: Tobacco Use Treatment Provided or Offered at Discharge  No Changes

Measure Information Form  SUB 1: Alcohol Use Screening  SUB 2: Alcohol Use Brief Intervention Provided or Offered  Please read measure information and me with any questions.

Measure Information Form  OP 10: Abdomen CT: Use of Contrast Material  Claims Based  Thresholds for SFY2016 are based on Hospital Compare data  Will use 3 rd and 4 th Qtrs 2015 Medicaid Claims for the SFY2016 program.

Alphabetical Data Dictionary  Data Elements with No Changes  Admission Date  Birth Date  Birth Time  Clinical Trial  Discharge Date  Discharge Disposition  First Name  ICD-9-CM Other Diagnosis Codes  ICD-9-CM Other Procedure Codes  ICD-9-CM Other Procedure  Dates  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code  ICD-9-CM Principal Procedure Date  Last Name  Patient Identifier  Prescription for Tobacco Cessation Medication  Reason for No Tobacco Cessation Medication at Discharge  Referral for Outpatient Tobacco Cessation Counseling  Sex  Tobacco Use Treatment FDA-Approved Cessation Medication

Alphabetical Data Dictionary  Admission to NICU  Removed, “…to receive critical care services…” from the Suggested Data Collection Question  Notes for Abstraction:  If the newborn is admitted to the NICU for observation or transitional care, select allowable value “no.” Transitional care is defined as a stay of 4 hours or less in the NICU  If an order to admit to the NICU is not found in the medical record, there must be supporting documentation present in the medical record indicating that the newborn received critical care services in the NICU in order to answer “yes.” Examples of supporting documentation include, but are not limited to the NICU admission assessment and NICU flow sheet.

Alphabetical Data Dictionary  Alcohol Use Status  The patient must be screened for alcohol use within the first three days of admission  The CAGE tool is not an acceptable screening tool for this measure set  An example of an Audit-C form is attached  New Data Element – Please me with any questions

Alphabetical Data Dictionary  Brief Intervention  Definition: A brief intervention focuses on increasing the patient’s understanding of the impact of substance use on his or her health and motivating the patient to change risky behaviors.  The components of the intervention include feedback concerning the quantity and frequency of alcohol consumed by the patient in comparison with national norms; a discussion of negative physical, emotional, and occupational consequences; and a discussion of the overall severity of the problem.  The qualified health care professional engages the patient in a joint decision-making process regarding alcohol use and plans for follow- up care are discussed and agreed to.  New Data Element – Please me with any questions

Alphabetical Data Dictionary  Comfort Measures Only  Notes for Abstraction  New – Discussion of comfort measures  State-authorized portable orders (SAPOs)  Documentation of an inclusion term in the following situations should be disregarded. Continue to review the remaining physician/APN/PA documentation for acceptable inclusion terms. If the ONLY documentation found is an inclusion term in the following situation, select value “4.”  See list of these inclusion terms on page 100  If there is physician/APN/PA documentation of an inclusion term in one source that indicates the patient is Comfort Measures Only, AND there is physician/APN/PA documentation of an inclusion term in another source that indicates the patient is NOT CMO, the source that indicates the patient is CMO would be used to select value “1,” “2,” or “3” for this data element.  See examples on page 101

Alphabetical Data Dictionary  Comfort Measures Only – continued  Suggested Data Sources – New  Consultation notes  History and physical  Inclusion Guidelines for Abstraction - New  Terminal extubation

Alphabetical Data Dictionary  Exclusive Breast Milk Feeding  Notes for Abstraction  If the newborn received drops of water or formula dribbled onto the mother’s breast to stimulate latching and not an actual feeding, select “Yes.”

Alphabetical Data Dictionary  Gestational Age  Notes for Abstraction  If the patient has not received prenatal care, select allowable value “UTD.”  If the gestational age entered by the clinician in the first document listed above is obviously incorrect (in error) but it is a valid number, or two different numbers are listed in the first document, and the correct number can be supported with other documentation in the other acceptable data sources in the medical record, the correct number may be entered.

Alphabetical Data Dictionary  Hospital Stay > 24 Hours  This is the actual time the baby leaves the hospital  Suggested Data Sources – New  Nurses’ discharge documentation

Alphabetical Data Dictionary  Labor  Notes for Abstraction  Documentation of labor by the clinician should be abstracted at face value. There is no requirement for acceptable descriptors to be present in order to answer “yes” to labor.  Documentation of regular contractions or cervical change without mention of labor cannot be used to answer “yes” to labor.

Alphabetical Data Dictionary  Parity  Notes for abstraction (page 123)  If the number for parity documented in the EHR includes the delivery for the current hospitalization, parity should be answered as one number less than the number documented.  If primigravida is documented select zero for parity.

Alphabetical Data Dictionary  Prior Uterine Surgery  Inclusion Guidelines for Abstraction – New  History of cornual ectopic pregnancy

Alphabetical Data Dictionary  Reason for No Tobacco Cessation Medication During the Hospital Stay  Notes for Abstraction  The timeframe for documenting a reason for not administering FDA- approved tobacco cessation medications must have occurred within the first three days of admission. The day after admission is defined as the first day.

Alphabetical Data Dictionary  Reason for Not Exclusively Feeding Breast Milk  Allowable Values  1. There is documentation by physician/advanced practice nurse (APN)/physician assistant (PA)/certified nurse midwife (CNM)/international board certified lactation consultant (IBCLC)/certified lactation counselor (CLC) of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition with which breast milk feeding should be avoided.  2. There is documentation by physician/APN/PA/CNM/IBCLC/CLC/RN that the newborn’s mother’s initial feeding plan for the hospitalization included formula upon admission of the newborn.

Alphabetical Data Dictionary  Reason for Not Exclusively Feeding Breast Milk – Continued  Notes for Abstraction  Last Bullet, page 137 – Bottle is a method of feeding and is not the same as formula. Bottle cannot be used interchangeably for formula, since breast milk can also be fed via a bottle. – I am still seeing a lot of “bottle” documentation instead of “formula.”  The notes for abstraction have changed. Please read all and me if you have any questions.  Suggested Data Sources – New  Nursing Assessment  Inclusion Guidelines for Abstraction  2 nd bullet, page 138 – Newborn and mother will be separated after discharge from the hospital, and the mother will not be providing care for the newborn after the hospitalization. Some examples include, but are not limited to: adoption, foster home placement, surrogate delivery, incarceration of the mother.

Alphabetical Data Dictionary  Specimen Collection  Must be done prior to discharge  Specimen Collection Date, Specimen Collection Time, Specimen Submission, Specimen Submission Date, Specimen Submission Time  Suggested Data Sources for all NBS Data Elements  Hospital’s laboratory report: As long as there is a copy of the NBS tool in the medical record  Arkansas Department of Health Newborn Screening Results Report  Note: This can only be used to document the date and time the specimen was collected and that it was submitted. Do not use the “Received” date or time when abstracting the date and time of submission.

Alphabetical Data Dictionary  Tobacco Use Status  Documentation of the adult patient’s tobacco use status within the past 30 days prior to the day of hospital admission.  Allowable Values – New  6. The patient was not screened for tobacco use during the first three days of admission because of cognitive impairment  Notes for Abstraction  Last bullet, page 153 – If there is documentation that the patient has temporary cognitive impairment due to acute substance use (e.g., overdose or acute intoxication) value “6” cannot be selected.  See examples on page 153

Alphabetical Data Dictionary  Tobacco Use Treatment Practical Counseling  Definition: The components of practical counseling require interaction with the patient to address the following: recognizing danger situations, developing coping skills, and providing basic information about quitting.  There must be documentation in the medical record that the patient received all components of practical counseling in a face to face setting.

Appendices  Appendix A  Table Complication Mainly Related to Pregnancy  Table Normal Delivery and Other Indications for Care  Table Complication Mainly in the Course of Labor and Delivery  Table Complication of the Peurperium  Table Medical Induction of Labor  Table Cesarean Section  Table Planned Cesarean Section in Labor  Table Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation  Table Outcome of Delivery  Table Multiple Gestations and Other Presentations

Appendices  Appendix A – Continued  Table Liveborn Newborn  Table Single Liveborn Newborn  Table Galactosemia  Table Parenteral Infusion  Table Premature Newborns  Table 12.3 Pregnancy

Appendices  Appendix B  Hospitals with a Qualifying Level III NICU  Appendix C  Table 9.1 FDA-Approved Tobacco Cessation Medications

Appendix H Table 2.6

AUDIT-C e-form Example

Q&A