Arkansas Medicaid Inpatient Quality Incentive Specifications Manual - SFY 2020 VERSION 9.0 07/01/2019 12/31/2019
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Arkansas Medicaid
Inpatient Quality Incentive
Specifications Manual
SFY 2020
VERSION 9.0 • 07/01/2019 - 12/31/2019
Table of Contents
Introduction .................................................................................................................................................. 3
Medicaid Inpatient Quality Incentive Criteria ............................................................................................ 5
State Fiscal Year 2020 .............................................................................................................................. 5
Overview .............................................................................................................................................. 5
Criteria .................................................................................................................................................. 5
Bonus payments ................................................................................................................................. 5
Performance Measures: OBS 4, 5a, 6, and 9; TOB 1, 2, 3, and BHS 1 ........................................... 5
Submission measures OBS 5, BHS 2 ............................................................................................... 5
Structural measures OBS 8, HIV 1, OBH 2, OBH 3 .......................................................................... 6
Outcome measure: OBH 1.................................................................................................................. 6
Sampling requirements ...................................................................................................................... 6
Validation ............................................................................................................................................. 6
Measure Information Forms and Flowcharts ............................................................................................ 9
Perinatal care (PC) initial patient population ............................................................................................. 9
Measure Set: Obstetric Services ............................................................................................................. 16
Set measure ID: OBS-4 ..................................................................................................................... 16
Set measure ID: OBS-5 ..................................................................................................................... 21
Set measure ID: OBS-6 ..................................................................................................................... 26
Set measure ID: OBS-9 ..................................................................................................................... 32
Measure set: Tobacco Treatment ........................................................................................................... 35
Set measure ID: TOB-1 ..................................................................................................................... 35
Set measure ID: TOB-2 ..................................................................................................................... 39
Set measure ID: TOB-3 ..................................................................................................................... 46
Measure Set: Behavioral Health Services ............................................................................................... 54
Set measure ID: BHS-1 ..................................................................................................................... 54
Set measure ID: BHS-2 ..................................................................................................................... 58
Measure Set: Structural Measures .......................................................................................................... 62
Set Measure ID: OBS-8 ..................................................................................................................... 62
Set Measure ID: HIV-1 ....................................................................................................................... 62
Set Measure ID: OBH-2 ..................................................................................................................... 62
Set Measure ID: OBH-3 ..................................................................................................................... 63
Measure Set: Outcome Measures ........................................................................................................... 64
Set Measure ID: OBH-1 ..................................................................................................................... 64
Data Element Abstraction Resources...................................................................................................... 66
Alphabetical Data Dictionary .................................................................................................................... 67
Data element name: Breast Milk Feeding – Observe and Assess Breastfeeding ................................. 67
Data element name: Breast Milk Feeding – Provide Advice and Instructions to Patient ........................ 68
Data element name: Discharge Code ..................................................................................................... 69
Data Element Name: ED Patient ............................................................................................................. 71
Data element name: Suicide Risk Screening in the Emergency Department ........................................ 73
Data element name: Suicide Risk Screening Plan for Follow-up Care ................................................... 74
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Data element name: Suicide Risk Screening Result............................................................................... 75
Appendix A – Diagnosis & Procedure Code Tables .............................................................................. 76
BHS diagnosis code tables .............................................................................................................. 76
OBS diagnosis code tables .............................................................................................................. 76
Appendix B ̶ Hospitals with Acceptable NICU Classification................................................................ 76
Appendix C – Tobacco Approved Medications ...................................................................................... 77
References .................................................................................................................................................. 78
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
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Introduction
This is the AFMC Data Abstraction Specifications and Guidelines for the Inpatient
Quality Incentive project for SFY2020. The measures were carefully selected to improve
care for a large number of Arkansans, including Arkansas Medicaid beneficiaries.
An AFMC data collection tool will be available for hospitals to begin collecting the data
for 3rd Quarter 2019 and 4th Quarter 2019 discharges.
The criteria were developed jointly by Arkansas Medicaid, the Arkansas Hospital
Association, AFMC and the advisory committee, which is made up of hospital quality
professionals.
This manual describes the data elements required to collect and submit the data for the
Obstetric, Tobacco Treatment, Behavioral Health Screening, and Obstetric Hemorrhage
measures for the Medicaid Inpatient Quality Incentive program for SFY 2020. It includes
information necessary for defining and formatting the data elements, as well as the
allowable values for each data element required for the Obstetric (OBS), Tobacco
Treatment (TOB), Behavioral Health Screening (BHS) and Obstetric Hemorrhage (OBH)
measures.
We have included information and links from the CMS Specifications Manual for
National Hospital Inpatient Quality Measures, the CMS Specifications Manual for
National Hospital Outpatient Quality Measures and the Joint Commission Specifications
Manual. When any information in these manual changes, the information will be
provided to hospitals participating in the IQI project via release notes.
Please note: all highlighted text is new for SFY2020.
General Abstraction Guidelines
The General Abstraction Guidelines are a resource designed to assist abstractors in
determining how a question should be answered. The abstractor should first refer to the
specific notes and guidelines under each data element. These instructions should take
precedence over the following General Abstraction Guidelines. All of the allowable values
for a given data element are outlined, and notes and guidelines are often included which
provide the necessary direction for abstracting a data element. It is important to utilize the
information found in the notes and guidelines when entering or selecting the most
appropriate answer.
Suggested data sources
Unless otherwise specified in the data element, the suggested data sources are listed in
alphabetical order, not priority order.
• Suggested data sources are designed to provide guidance to the abstractor as to
the locations/sources where the information needed to abstract a data element
will likely be found. However, the abstractor is not limited to these sources for
abstracting the information and must review the entire medical record unless
otherwise specified in the data element.
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• In some instances, a data element may restrict the sources that may be used to
gain the information, list a priority in which the sources should be used or may
restrict documentation by only physician/advanced practice nurse/physician
assistant. If so, these sources will be identified and labeled as “Excluded Data
Sources,” “ONLY ACCEPTABLE SOURCES,” “Priority Source,” or
“PHYSICIAN/APN/PA DOCUMENTATION ONLY.” If, after due diligence, the
abstractor determines that a value is not documented or is not able to determine
the answer value, the abstractor must select “unable to determine (UTD)” as the
answer if that option is available.
• Hospitals often label forms and reports with unique names or titles. Suggested
data sources are listed by commonly used titles; however, information may be
abstracted from any source that is equivalent to those listed.
Example: If the “nursing admission assessment” is listed as a suggested
source, an acceptable alternative might be titled “nurses’ initial
assessment” or “nursing database.”
Note: Element-specific notes and guidelines should take precedence over
the general abstraction guidelines.
Inclusions/exclusions
• Inclusions are “acceptable terms” that should be abstracted as positive findings
(e.g., “Yes”).
• Inclusion lists are limited to those terms that are believed to be most commonly
used in medical record documentation. The list of inclusions should not be
considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are “unacceptable terms” that should be abstracted as negative
findings (e.g., “No”).
• Exclusion lists are limited to those terms an abstractor may most frequently
question whether or not to abstract as a positive finding for a particular element
(e.g., “cardiomyopathy” is an unacceptable term for heart failure and should be
abstracted as "No"). The list of exclusions should not be considered all-
inclusive, unless otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the
inclusion takes precedence over the exclusion and would be abstracted as a
positive finding (e.g., answer “Yes”), unless otherwise specified in the data
element.
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
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Medicaid Inpatient Quality Incentive Criteria
State Fiscal Year 2020
Overview
The 2020 program is aimed at identifying and rewarding hospitals that provide a higher
level of care to Arkansas Medicaid beneficiaries. The program will focus on eight
performance measures, two submission measures, one outcome measure and four
structural measures.
Criteria
• Hospitals must submit data on all eligible measures and have a minimum of five
Arkansas Medicaid cases per eligible topic for Q3 and Q4 of 2019.
• Hospitals must pass 80% of the eligible measures (see thresholds).
• If measure denominator is zero after data analysis, the hospital will not be eligible
for that measure.
• Hospitals must pass validation.
Bonus payments
• Qualifying PPS hospitals will receive 5.8% of their per diem, or up to $50 per day,
on their Medicaid primary discharge (excluding dual-eligible beneficiaries and
those under one year of age).
• Hospitals not eligible for a bonus payment but would like to participate in the
evaluation for recognition will have the same requirement.
Performance Measures: OBS 4, 5a, 6, and 9; TOB 1, 2, 3, and BHS 1
• Threshold 1: Performance in Q3 and Q4 of 2019 at or above the 75th percentile
from Q3 and Q4 of 2018.
o Exceptions: OBS 4 performance must be 3% or below and OBS 6 must be
22% or lower for combined Q3 and Q4 of 2018.
• Threshold 2: Hospitals must achieve a 35% reduction in failure rate based on
submitted data from Q3 and Q4 of 2018.
o Exceptions: OBS 4 performance must be 3% or below, OBS 6 must be
22% or lower, and OBS 5a and OBS 9 performance must have a 25%
reduction in failure rate based on submitted data from Q3 and Q4 of 2018.
• TOB, OBS 5a/OBS 9, and BHS 1: Performance of 50% minimum must be
achieved to qualify for passing.
Submission measures OBS 5, BHS 2
• OBS 5: Hospitals will abstract and submit 100% of their OBS Newborn
population.
• BHS 2: Hospitals will abstract and submit an adequate sample of their BHS
population.
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Structural measures OBS 8, HIV 1, OBH 2, OBH 3
• OBS 8: Document the number of patients who were screened for depression and
the total number of deliveries.
• HIV 1: Document the number of patients who had documentation of HIV status
prior to delivery and the total number of deliveries
• OBH 2: Does your facility have a hemorrhage cart immediately available on all
maternity units? (Yes/No)
• OBH 3: Does your hospital have an OB hemorrhage policy and procedure
(reviewed and updated in the last 2-3 years) that:
▪ Provides a unit-standard approach using a stage-based
management plan with checklists
▪ Ensures availability to OB hemorrhage supplies at all times
Outcome measure: OBH 1
• OBH 1: Severe Maternal Morbidity
Sampling requirements
• AFMC will provide a monthly Arkansas Medicaid case count per topic in.
• Hospitals will have the option to abstract 100% of the cases or select a random
sample.
o Exception: There will be no sampling option for OBS measures. Hospitals
will abstract 100% of their OBS Medicaid population.
• The monthly patient list will be based on Arkansas Medicaid paid claims (either
primary or secondary if paid by Medicaid). This number may differ from the actual
number of cases a hospital has during a quarter.
Validation
• Two randomly selected charts from each topic per quarter for Q3 and Q4 of 2019
will be requested for validation.
• OBS 8, HIV 1, and the new OBH measures will not have charts validated.
• To pass validation, a combined score of 80% across both quarters will be
required.
# of Eligible # of Measures
Measures Required to Pass
15 12
5 4
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
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15 Quality Incentive Measures for SFY 2020
(Must pass 80% of the eligible measures)
PERFORMANCE CRITERIA TO PASS VALIDATION
MEASURES MEASURE
OBS 4: EARLY ELECTIVE Must be 3% or below for Two randomly selected charts from OBS
DELIVERY combined Quarter 3 and Quarter Mother from each Quarter 3 and 4, 2019
4, 2019
OBS 5a: BREASTMILK FEEDING Must meet thresholds 1 or 2 Two randomly selected charts from OBS
– OBSERVATION/ASSESSMENT listed above for combined Newborn from each Quarter 3 and 4, 2019
Quarter 3 and Quarter 4, 2019
OBS 6: CESAREAN SECTION: Must be 22% or lower for Two randomly selected charts from OBS
NULLIPAROUS WOMEN combined Quarter 3 and Quarter Mother from each Quarter 3 and 4, 2019
4, 2019
OBS 9: BREASTMILK FEEDING- Must meet thresholds 1 or 2 Two randomly selected charts from OBS
PROVIDE ADVICE AND listed above for combined Mother from each of Quarters 3 and 4,
INSTRUCTIONS TO PATIENT Quarter 3 and Quarter 4, 2019 2019
TOB 1: TOBACCO USE Must meet thresholds 1 or 2 Two randomly selected charts from TOB
SCREENING listed above for combined measure set from each Quarter 3 and 4,
Quarter 3 and Quarter 4, 2019 2019
TOB 2: TOBACCO USE Must meet thresholds 1 or 2 Two randomly selected charts from TOB
TREATMENT PROVIDED OR listed above for combined measure set from each Quarter 3 and 4,
OFFERED Quarter 3 and Quarter 4, 2019 2019
TOB 3: TOBACCO USE Must meet thresholds 1 or 2 Two randomly selected charts from TOB
TREATMENT PROVIDED OR listed above for combined measure set from each Quarter 3 and 4,
OFFERED AT DISCHARGE Quarter 3 and Quarter 4, 2019 2019
BHS 1: SUICIDE RISK Must meet thresholds 1 or 2 Two randomly selected charts from BHS
SCREENING listed above for combined from each Quarter 3 and 4, 2019
Quarter 3 and Quarter 4, 2019
OUTCOME CRITERIA TO PASS VALIDATION
MEASURES MEASURE
OBH 1: SEVERE MATERNAL Baseline score will be There will be no validation for this
MORBIDITY established from combined measure
quarter 3 and quarter 4 2019
claims data
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)SUBMISSION MEASURES CRITERIA TO PASS VALIDATION
MEASURE
OBS 5: EXCLUSIVE BREAST Abstract and submit 100% of Two randomly selected charts from OBS
MILK FEEDING OBS Newborn cases for Newborn from each Quarter 3 and 4,
Quarters 3 and 4, 2019 2019.
BHS 2: SUICIDE RISK Abstract and submit an Two randomly selected charts from BHS
SCREENING FOLLOW-UP adequate sample for Quarters 3 from each Quarter 3 and 4, 2019
and 4, 2019
STRUCTURAL MEASURES CRITERIA TO PASS VALIDATION
MEASURE
OBS 8: DEPRESSION Document the number of There will be no validation for this
SCREENING IN PREGNANCY patients who were screened for measure in SFY2020
depression and the total number
of deliveries during Quarters 3
and 4, 2019
HIV 1: HIV STATUS Document the number of There will be no validation for this
DOCUMENTATION patients who had documentation measure in SFY2020
of HIV status prior to delivery
and the total number of
deliveries during Quarters 3 and
4, 2019
OBH 2: Hemorrhage Cart Do you have a hemorrhage cart There will be no validation for this
immediately available on all measure in SFY2020
maternity units? (Yes/No)
OBH 3: Hemorrhage Unit Policy Does your hospital have an OB There will be no validation for this
hemorrhage policy and measure in SFY2020
procedure (reviewed and
updated in the last 2-3 years)
that:
●Provides a unit-standard
approach using a stage-based
management plan with
checklists
●Ensures availability to OB
hemorrhage supplies at all times
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Measure Information Forms and Flowcharts
Perinatal care (PC) initial patient population
The PC measure set is unique in that there are two distinct initial patient populations
within the measure set: mothers and newborns.
Mothers
The population of the PC-Mother measures (PC-01, 02, and 03) are identified using four
data elements:
• Admission date
• Birth date
• Discharge date
• ICD-10-PCS principal or other procedure code
Patients admitted to the hospital for inpatient acute care are included in the PC Mother
Initial sampling group if they have: ICD-10-PCS Principal or Other Procedure Codes as
defined in Appendix A, Table 11.01.1; a Patient Age (admission date–birth date) ≥8
years andMeasures Initial Patient Population Definition
PC-05 The count of all patients in PC-Newborns with Breastfeeding
Patients admitted to the hospital for inpatient acute care are included in one of the PC-
Newborn subpopulations if they have:
1. NO ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table
11.10.2,
2. ONE of the following:
o an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables
11.12, 11.13, 11.14 Or Birth Weight >= 500g and =1500g with ANY OF THE FOLLOWING:
▪ an ICD-10-PCS-Principal or Other Procedure Code as defined in
Appendix A, Tables 11.18 or 11.19
▪ Discharge Disposition of 6 (expired) or a Missing Discharge
Disposition
▪ NO ICD-10-CM Principal Diagnosis Code as defined in Appendix A,
Table 11.10.3
o Birth Weight Missing or Unable To Determine (UTD).
3. NO ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.20 Or
Birth Weight < 500g
There is no sampling for this measure.
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Newborns with Breast Feeding - Patient Age at admission (Admission Date —
Birthdate) ≤ 2 days, Length of Stay (Discharge Date - Admission Date) ≤ 120 days, an
ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.20.1, NO ICD-
10-CM Other Diagnosis Codes as defined in Appendix A, Table 11.21, NO ICD-10-
PCS-Principal or Other Procedure Code as defined in Appendix A, Table 11.22 are
included in this subpopulation and are eligible to be sampled.
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Measure Set: Obstetric Services Set measure ID: OBS-4 Performance measure name: Elective delivery Description: Patients with elective vaginal deliveries or elective cesarean births at ≥37 and
Denominator statement: Patients delivering newborns with ≥37 and
Abstraction resources:
https://manual.jointcommission.org/releases/TJC2019A/DataDictionaryIntroductionTJC.
html#AlphaDataElementList
Selected references:
• American Academy of Family Physicians. (2000). Tips from Other Journals:
Elective induction doubles cesarean delivery rate, 61, 4. Retrieved December 29,
2008 at: http://www.aafp.org/afp/20000215/tips/39.html.
• American College of Obstetricians and Gynecologists. (November 1996). ACOG
Educational Bulletin.
• Clark, S., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal
and maternal outcomes associated with elective delivery. [Electronic Version].
Am J Obstet Gynecol. 200:156.e1-156.e4.
• Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and
outcomes. [Electronic Version]. J Reprod Med. 50(4):235-40.
• Tita, A., Landon, M., Spong, C., Lai, Y., Leveno, K., Varner, M, et al. (2009).
Timing of elective repeat cesarean delivery at term and neonatal outcomes.
[Electronic Version]. NEJM. 360:2, 111-120.
Original performance measure source/developer:
Hospital Corporation of America ̶ Women's and Children's Clinical Services
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Measure Set: Obstetric Services
Set measure ID: OBS-5
Measure name:
• OBS-5 Exclusive Breast Milk Feeding
• OBS-5a Breast Milk Feeding – Observe and Assess Breastfeeding
Description:
• OBS-5: Exclusive breast milk feeding during the newborn's entire hospitalization
• OBS-5a: Newborns delivered at this hospital who received breast milk feeding
observation and assessment from qualified hospital staff
Rationale: Exclusive breast milk feeding for the first six months of neonatal life has long
been the expressed goal of World Health Organization (WHO), Department of Health
and Human Services (DHHS), American Academy of Pediatrics (AAP), and American
College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its
position (ACOG, 2007). A recent Cochrane review substantiates the benefits (Kramer et
al., 2002). Much evidence has now focused on the prenatal and intrapartum period as
critical for the success of exclusive (or any) BF (Centers for Disease Control and
Prevention [CDC], 2007; Petrova et al., 2007; Shealy et al., 2005; Taveras et al., 2004).
Exclusive breast milk feeding rate during birth hospital stay has been calculated by the
California Department of Public Health for the last several years using newborn genetic
disease testing data. Healthy People 2010 and the CDC have also been active in
promoting this goal.
Type of measure: Process
Improvement noted as: Increase in the rate
Numerator statement:
• OBS-5: Newborns that were fed breast milk only since birth
• OBS-5a: Newborns that received breast milk observation and assessment from
qualified hospital staff
Included populations: Not applicable
Excluded populations: None
Data elements:
• Exclusive breast milk feeding
• Breast milk feeding – observe and assess breastfeeding
Denominator statement:
Single-term newborns discharged alive from the hospital
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Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Included populations:
Live-born newborns with ICD-10-CM Principal Diagnosis Code for single live-born
newborn as defined in Appendix A, Table 11.20.1
Excluded populations:
• Admitted to the neonatal intensive care unit (NICU) at this hospital during the
hospitalization
• ICD-10-CM Other Diagnosis Codes for galactosemia as defined in Appendix A,
Table 11.21
• ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes
for parenteral nutrition as defined in Appendix A, Table 11.22
• Experienced death
• Length of stay >120 days
• Patients transferred to another hospital
• Patients who are not term or withSelected references:
• American Academy of Pediatrics. (2005). Section on Breastfeeding. Policy
Statement: Breastfeeding and the Use of Human Milk. Pediatrics.115:496—
506.
• American College of Obstetricians and Gynecologists. (Feb. 2007). Committee
on Obstetric Practice and Committee on Health Care for Underserved Women.
Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion 361.
• California Department of Public Health. (2017). Division of Maternal, Child and
Adolescent Health, Breastfeeding Initiative, In-Hospital Breastfeeding Initiation
Data, Hospital of Occurrence: Available at:
https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/In-
Hospital-Breastfeeding-Initiation-Data.aspx
• Centers for Disease Control and Prevention. (Aug 3, 2007). Breastfeeding trends
and updated national health objectives for exclusive breastfeeding--United
States birth years 2000-2004. MMWR - Morbidity & Mortality Weekly Report.
56(30):760-3.
• Centers for Disease Control and Prevention. (2017). Division of Nutrition,
Physical Activity and Obesity. Breastfeeding Report Card. Available at:
https://www.cdc.gov/breastfeeding/data/reportcard.htm
• Ip, S., Chung, M., Raman, G., et al. (2007). Breastfeeding and maternal and
infant health outcomes in developed countries. Rockville, MD: US Department
of Health and Human Services. Available at:
https://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
• Kramer, M.S. & Kakuma, R. (2002).Optimal duration of exclusive breastfeeding.
[107 refs] Cochrane Database of Systematic Reviews. (1):CD003517.
• Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and one-
month exclusive breastfeeding in association with the in-hospital feeding
modality. Breastfeeding Medicine. 2(2):92-8.
• Shealy, K.R., Li, R., Benton-Davis, S., & Grummer-Strawn, L.M. (2005).The CDC
guide to breastfeeding interventions. Atlanta, GA: US Department of Health
and Human Services, CDC. Available at:
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf.
• Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego,
V.H., Miroshnik, I., & Lieu, T.A. (2004). Opinions and practices of clinicians
associated with continuation of exclusive breastfeeding. Pediatrics.
113(4):e283-90.
• US Department of Health and Human Services. (2007). Healthy People 2010
Midcourse Review. Washington, DC: US Department of Health and Human
Services. Available at:
https://www.healthypeople.gov/2010/data/midcourse/html/default.htm?visit=1
• World Health Organization. (2007). Indicators for assessing infant and young
child feeding practices. Washington, DC, USA: World Health Organization.
Available at:
http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf
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OBS-5a: Breastmilk Feeding – Observe and Assess Breastfeeding
Numerator: Newborns who received breastmilk feeding observation and assessment from qualified hospital
staff
Denominator: Single term newborns discharged alive from the hospital
Top section is same as OBS-5
Admission to =Y
NICU
=N
Exclusive
Breast Milk
Feeding
= Y or N
Observe/ = N/A
Assess
Breastfeeding
=N
=Y
D
In Measure
Population
E
In Numerator
Population
B
Not Measure
Population
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Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Measure set: Obstetric Services
Set measure ID: OBS-6
Measure name: Cesarean Birth
Description: Nulliparous women with a term, singleton baby in a vertex position
delivered by cesarean birth
Rationale: The removal of any pressure to not perform a cesarean birth (CB) has
led to a skyrocketing of hospital, state and national CB rates. Some hospitals now
have CB rates greater than 50%. Hospitals with CB rates at 15–20% have infant
outcomes that are just as good and better maternal outcomes (Gould et al., 2004).
There are no data showing higher rates improve any outcomes, yet the CB rates
continue to rise. This measure seeks to focus attention on the most variable
portion of the CB epidemic: the term labor CB in nulliparous women. This
population segment accounts for the large majority of the variable portion of the
CB rate, and is the area most affected by subjectivity.
As compared with other CB measures, what is different about NTSV CB rate (low-
risk primary CB in first births) is that there are clear-cut quality improvement
activities that can be carried out to address the differences. Main et al. (2006)
found that more than 60% of the variation among hospitals can be attributed to
first-birth labor induction rates and first-birth early labor admission rates. The
results showed if labor was forced when the cervix was not ready, the outcomes
were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines
can make a difference in labor outcomes. Many authors have shown that
physician factors, rather than patient characteristics or obstetric diagnoses are the
major driver for the difference in rates within a hospital (Berkowitz, et al., 1989;
Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen
in all populations studied is striking according to Menacker (2006). Hospitals within
a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and
Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have
rates with a three- to five-fold variation.
Type of measure: Outcome
Improvement noted as: Decrease in the rate
Numerator statement: Patients with cesarean births
Included populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS
Other Procedure Codes for cesarean birth as defined in Appendix A, Table 11.06
Excluded populations: None
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Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Data elements:
• ICD-10-PCS Other Procedure Codes
• ICD-10-PCS Principal Procedure Code
Denominator statement: Nulliparous patients delivered of a live-term singleton
newborn in vertex presentation
Included populations:
• ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure
Codes for delivery as defined in Appendix A, Table 11.01.1
• Nulliparous patients with ICD-10-CM Principal Diagnosis Code or ICD-10-
CM Other Diagnosis Codes for outcome of delivery as defined in Appendix
A, Table 11.08 and with a delivery of a newborn with 37 weeks or more of
gestation completed
Excluded populations:
• ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis
Codes for multiple gestations and other presentations as defined in
Appendix A, Table 11.09
• Less than eight years of age
• Older than or equal to 65 years of age
• Length of stay >120 days
• Gestational ageSampling: Hospitals will abstract 100% of the OBS-Mother population available.
Data reported as: Aggregate rate generated from count data reported as a
proportion.
Abstraction resources:
https://manual.jointcommission.org/releases/TJC2019A/DataDictionaryIntroductio
nTJC.html#AlphaDataElementList
Selected references:
• Agency for Healthcare Research and Quality. (2002). AHRQ Quality
Indicators Guide to Inpatient Quality Indicators: Quality of Care in
Hospitals Volume, Mortality, and Utilization. Revision 4 (December 22,
2004). AHRQ Pub. No. 02-RO204.
• Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite
guidelines on intrapartum care in “standard primigravida.” Eur J Obstet
Gynecol Reprod Biol.115:28-31.
• American College of Obstetricians and Gynecologists. (2000). Task Force
on Cesarean Delivery Rates. Evaluation of Cesarean Delivery.
(Developed under the direction of the Task Force on Cesarean Delivery
Rates, Roger K. Freeman, MD, Chair, Arnold W. Cohen, MD, Richard
Depp III, MD, Fredric D. Frigoletto Jr, MD, Gary D.V. Hankins, MD, Ellice
Lieberman, MD, DrPH, M. Kathryn Menard, MD, David A. Nagey, MD,
Carol W. Saffold, MD, Lisa Sams, RNC, MSN and ACOG Staff: Stanley
Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth Steele).
• Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C.
(2002). Hospital primary cesarean delivery rates and the risk of poor
neonatal outcomes. Am J Obstet Gynecol. 187(3):721-7.
• Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment
methodologies. Am J Obstet Gynecol.102:45-51.
• Bailit, J.L., Love, T.E., & Dawson, N.V. (2006). Quality of obstetric care and
risk-adjusted primary cesarean delivery rates. Am J Obstet
Gynecol.194:402.
• Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob
Gyn Sur. 62:207-213.
• Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of
physician characteristics on the cesarean birth rate. Am J Obstet
Gynecol. 161:146-9.
• California Office of Statewide Hospital Planning and Development. (2017).
Hospital Volume and Utilization Indicators for California, Retrieved from
the Internet on February 22, 2018 at:
https://www.oshpd.ca.gov/HID/AHRQ-Volume-Utilization.html
• Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M.
(1996). The standard primipara as a basis for inter-unit comparisons of
maternity care. Br J Obstet Gynecol. 103:223-9.
28
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)• Coonrod, D.V., Drachman, D., Hobson, P., & Manriquez, M. (2008).
Nulliparous term singleton vertex cesarean delivery rates: institutional
and individual level predictors. Am J Obstet Gynecol. 694-696.
• DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., &
Rosenthal, G.E. (2001). Risk adjusting cesarean delivery rates: a
comparison of hospital profiles based on medical record and birth
certificate data. Health Serv Res.36:959-77.
• Gould, J., Danielson, B., Korst, L., Phibbs, R., Chance, K.,& Main, E.K., et
al. (2004). Cesarean delivery rate and neonatal morbidity in a low-risk
population. Am J Obstet Gynecol, 104:11-19.
• Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician
factor in cesarean birth rates. N Engl J Med.320:706-9.
• Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of
perinatal care of the maternity unit and rate of cesarean in low-risk
nulliparas. Am J Obstet Gynecol. 107:1269-77.
• Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003).
Physician contribution to a cesarean delivery risk model. Am J Obstet
Gynecol.188:1579-85.
• Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality
improvement activities. Peds. 103: 374-383.
• Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale
obstetric quality-improvement program that focused on the nulliparous
patient at term. Am J Obstet Gynecol.190:1747-58.
• Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams,
C., et al., (2006). Is there a useful cesarean birth measure? Assessment
of the nulliparous term singleton vertex cesarean birth rate as a tool for
obstetric quality improvement. Am J Obstet Gynecol. 194:1644-51.
• Menacker, F. (2005).Trends in cesarean rates for first births and repeat
cesarean rates for low-risk women: United States, 1990-2003. Nat Vital
Stat Rep. 54(4): 1-5.
• Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2005). Coding of perineal lacerations and other complications of
obstetric care in hospital discharge data. Am J Obstet Gynecol.106:717-
25.
• U.S. Department of Health and Human Services. (2000). Healthy People
2010: Understanding and Improving Health. 2nd ed. Washington, DC:
U.S. Government Printing Office. Measure 16-9.
• Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2006). Accuracy of obstetric diagnoses and procedures in hospital
discharge data. Am J Obstet Gynecol. 194:992-1001.
Original performance measure source/developer:
California Maternal Quality Care Collaborative
29
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)30 Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020 Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)
31 Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020 Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)
Measure set: Obstetric Services
Set measure ID: OBS-9
Measure name: Breast Milk Feeding – Provide advice and instructions to patient
Description: Mothers who deliver at this hospital received breast milk feeding advice
and instructions from qualified hospital staff
Rationale: Exclusive breast milk feeding for the first six months of neonatal life has long
been the expressed goal of World Health Organization (WHO), Department of Health
and Human Services (DHHS), American Academy of Pediatrics (AAP) and American
College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its
position (ACOG, 2007). A recent Cochrane review substantiates the benefits (Kramer et
al., 2002). Much evidence has now focused on the prenatal and intrapartum period as
critical for the success of exclusive (or any) BF (Centers for Disease Control and
Prevention [CDC], 2007; Petrova et al., 2007; Shealy et al., 2005; Taveras et al., 2004).
Exclusive breast milk feeding rate during birth hospital stay has been calculated by the
California Department of Public Health for the last several years using newborn genetic
disease testing data. Healthy People 2010 and the CDC have also been active in
promoting this goal.
Type of measure: Process
Improvement noted as: Increase in the rate
Numerator statement: Patients who received breast milk feeding advice and
instructions from qualified hospital staff
Included populations: Patients who refused screening
Excluded populations: None
Data elements: Breast milk feeding – provide advice and instructions to patient
Denominator statement: All mothers who deliver live-born newborns at this hospital
Included populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other
Procedure Codes for delivery as defined in Appendix A, Table 11.01.1
Excluded populations:
• Younger than eight years of age
• Older than or equal to 65 years of age
• Length of stay >120 days
• ICD-10-PCS principal and other diagnosis codes Z371, Z374, and Z377
• In the event a mother will be leaving the hospital without the newborn
• Mother has a positive drug screen
32
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Data elements:
• Admission date
• Birth date
• Discharge date
• ICD-10-CM Other Diagnosis Codes
• ICD-10-CM Principal Diagnosis Code
Risk adjustment: No
Data collection approach: Retrospective data sources for required data elements
include administrative data and medical records.
Data accuracy: Variation may exist in the assignment of ICD-10-CM codes; therefore,
coding practices may require evaluation to ensure consistency.
Measure analysis suggestions: In order to identify areas for improvement, hospitals
may want to review results based on specific ICD-10 codes or patient populations. Data
could then be analyzed further determine specific patterns or trends to help reduce
cesarean births.
Sampling: Hospitals will abstract 100% of the OBS-Mother population that is available.
Data reported as: Aggregate rate generated from count data reported as a proportion
Selected reference:
Centers for Disease Control Breastfeeding
http://www.cdc.gov/breastfeeding/
OBS-9: Breast Milk Feeding – Provide advice and instructions to patient
33
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Numerator: Patients who received breast milk feeding advice and instructions from qualified hospital staff.
Denominator: All mothers who deliver live-born newborns in hospital
START
Cases that are included in the
OBS-Mother population
Include Stillbirth ICD-10-CM
Principle or
Other Diagnosis
Codes
Not Include Stillbirth
= 4 Breastmilk = 2
Feeding Advice/
Instruction
= 1 or 3
E
In Numerator
Population
D
In Measure
Population
B
Not In Measure
Population
STOP
34
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Measure set: Tobacco Treatment
Set measure ID: TOB-1
Performance measure name: Tobacco Use Screening
Description: Hospitalized patients who are screened within the first day of admission
for tobacco use (cigarettes, smokeless tobacco, pipe and cigars) within the past 30 days
Rationale: Tobacco use is the single greatest cause of disease in the United States
today and accounts for more than 435,000 deaths each year (CDC MMWR 2008;
McGinnis 1993). Smoking is a known cause of multiple cancers, heart disease, stroke,
complications of pregnancy, chronic obstructive pulmonary disease, other respiratory
problems, poorer wound healing and many other diseases (DHHS 2004). Tobacco use
creates a heavy cost to society as well as to individuals. Smoking-attributable health
care expenditures are estimated at $96 billion per year in direct medical expenses and
$97 billion in lost productivity (CDC 2007).
There is strong and consistent evidence that tobacco dependence interventions, if
delivered in a timely and effective manner, significantly reduce the user’s risk of
suffering from tobacco-related disease and improved outcomes for those already
suffering from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood
2003 and 1997; Rigotti 2008). Effective, evidence-based tobacco dependence
interventions have been clearly identified and include brief clinician advice, individual,
group, or telephone counseling, and use of FDA-approved medications. These
treatments are clinically effective and extremely cost-effective relative to other
commonly used disease prevention interventions and medical treatments.
Hospitalization (both because hospitals are a tobacco-free environment and because
patients may be more motivated to quit as a result of their illness) offers an ideal
opportunity to provide cessation assistance that may promote the patient’s medical
recovery. Patients who receive even brief advice and intervention from their care
providers are more likely to quit than those who receive no intervention.
Type of measure: Process
Improvement noted as: Increase in the rate
Numerator statement: The number of patients who were screened for tobacco use
status within the first day of admission (by end of Day 1)
Included populations: Patients who refused screening
Excluded populations: None
Data elements: Tobacco use status
Denominator statement: The number of hospitalized inpatients 18 years of age and
older
35
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Included populations: Not applicable
Excluded populations:
• Patients younger than 18 years of age
• Patient who are cognitively impaired
• Patients who have a duration of stay less than or equal to one day or greater
than 120 days
• Patients with Comfort Measures Only documented
Data elements:
• Admission date
• Birth date
• Comfort measures only
• Discharge date
• Tobacco use status
Risk adjustment: No
Data collection approach: Retrospective data sources for required data elements
include administrative data and medical record documents. Some hospitals may prefer
to gather data concurrently by identifying patients in the population of interest. This
approach provides opportunities for improvement at the point of care/service. However,
complete documentation includes the principal or other ICD-10 diagnosis and procedure
codes, which require retrospective data entry.
Data accuracy: Data accuracy is enhanced when all definitions are used without
modification. The data dictionary should be referenced for definitions and abstraction
notes when questions arise during data collection.
Measure analysis suggestions: Hospitals may wish to analyze data to show the rate
of those who were actually screened for tobacco use status, subtracting those that
refused the screen.
Sampling: Yes
Data reported as: Aggregate rate generated from count data reported as proportion
Abstraction resources:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPag
e%2FQnetTier3&cid=1228776364473
36
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Selected references:
• Baumeister, S. E., Schumann, A., Meyer, C., John, U., Volzke, H., & Alte, D. (2007).
Effects of smoking cessation on health care use: Is elevated risk of hospitalization
among former smokers attributable to smoking-related morbidity? Drug and Alcohol
Dependence, 88(2–3), 197–203.
• Centers for Disease Control and Prevention. (2014). Current cigarette smoking
among adults—United States, 2005–2013. Morbidity and Mortality Weekly Report
(MMWR), 63(47), 1108–1112. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a4.htm?s_cid=mm6347a4_w.
• Lightwood, J. M. (2003). The economics of smoking and cardiovascular disease.
Progress in Cardiovascular Diseases, 46(1), 39–78.
• Lightwood, J. M., & Glantz, S. A. (1997). Short-term economic and health benefits of
smoking cessation: Myocardial infarction and stroke. Circulation, 96(4), 1089–1096.
• Rigotti, N. A., Clair, C., Munafo, M. R., & Stead, L. F. (2012). Interventions for
smoking cessation in hospitalized patients. Cochrane Database of Systematic
Reviews. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001837.pub3/abstract.
• U.S. Department of Health and Human Services. (2014). The health consequences
of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-
of-progress/full-report.pdf .
• U.S. Department of Health and Human Services. (2008). Tobacco use and
dependence guideline panel. Treating tobacco use and dependence: 2008 update.
Rockville, MD: U.S. Department of Health and Human Services. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK63952/.
• U.S. Department of Health and Human Services. (2000). Reducing tobacco use: A
report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention.
37
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)38 Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020 Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)
Measure set: Tobacco Treatment
Set measure ID: TOB-2
Performance measure name: Tobacco Use Treatment Provided or Offered
Description:
Patients identified as tobacco product users within the past 30 days who receive or
refuse practical counseling to quit and receive or refuse FDA-approved cessation
medications during the hospital stay.
The measure is reported as an overall rate that includes all patients to whom tobacco
use treatment was provided, or offered and refused, and a second rate, a subset of the
first, which includes only those patients who received tobacco use treatment. The
Provided or Offered rate (TOB-2) describes patients identified as tobacco product users
within the past 30 days who receive or refuse practical counseling to quit AND receive
or refuse FDA-approved cessation medications during the hospital stay. The Tobacco
Use Treatment (TOB-2a) rate describes only those who received counseling AND
medication as well as those who received counseling and had reason for not receiving
the medication. Those who refused are not included.
Rationale: Tobacco use is the single greatest cause of disease in the United States
today and accounts for more than 480,000 deaths each year (CDC MMWR 2014).
Smoking is a known cause of multiple cancers, heart disease, stroke, complications of
pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer
wound healing, and many other diseases (DHHS 2014). Tobacco use creates a heavy
cost to society as well as to individuals. Smoking-attributable health care expenditures
are estimated to be at least $130 billion per year in direct medical expenses for adults,
and over $150 billion in lost productivity (DHHS 2014).
There is strong and consistent evidence that tobacco dependence interventions, if
delivered in a timely and effective manner, significantly reduce the user's risk of
suffering from tobacco-related disease and improve outcomes for those already
suffering from a tobacco-related disease (DHHS 2000; Baumeister 2007; Lightwood
2003 and 1997; Rigotti 2012). Effective, evidence-based tobacco dependence
interventions have been clearly identified and include brief clinician advice, individual,
group, or telephone counseling, and use of FDA-approved medications. These
treatments are clinically effective and extremely cost-effective relative to other
commonly used disease prevention interventions and medical treatments.
Hospitalization (both because hospitals are a tobacco-free environment and because
patients may be more motivated to quit as a result of their illness) offers an ideal
opportunity to provide cessation assistance that may promote the patient's medical
recovery. Patients who receive even brief advice and intervention from their care
providers are more likely to quit than those who receive no intervention (DHHS, 2008).
Type of measure: Process
Improvement noted as: Increase in the rate
39
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)Numerator statement: The number of patients who received or refused practical
counseling to quit AND received or refused FDA-approved cessation medications during
the hospital stay
Included populations:
• Patients who refuse counseling
• Patients who refuse FDA-approved cessation medication
Excluded populations (for FDA-approved medications only):
• Smokeless tobacco users
• Pregnant smokers
• Light smokers
• Patients with reasons for not administering FDA-approved cessation medication
Data elements:
• Reason for no tobacco cessation medication during the hospital stay
• Tobacco use status
• Tobacco use treatment FDA-approved cessation medication
• Tobacco use treatment practical counseling
Denominator statement: The number of hospitalized inpatients 18 years of age and
older identified as current tobacco users
Included populations: Not applicable
Excluded populations:
• Patients less than 18 years of age
• Patients who are cognitively impaired
• Patients who are not current tobacco users
• Patients who refused or were not screened for tobacco use during the hospital
stay
• Patients who have a duration of stay less than or equal to one day or greater
than 120 days
• Patients with Comfort Measures Only documented
Data elements:
• Admission date
• Birth date
• Comfort measures only
• Discharge date
• Tobacco use status
Risk adjustment: No
Data collection approach: Retrospective data sources for required data elements
include administrative data and medical records. Some hospitals may prefer to gather
data concurrently by identifying patients in the population of interest. This approach
40
Arkansas Medicaid Inpatient Quality Incentive Guidelines SFY2020
Discharges 07/01/2019 (3Q2019) through 12/31/2019 (4Q2019)You can also read
