Definitions

Find the definitions for all measures in the CAHMPAS system and commonly used acronyms in the Flex program below.

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AHA

The American Hospital Association (AHA) represents and serves all types of hospitals, health care networks, and their patients and communities. The AHA Annual Survey of Hospitals profiles a universe of more than 6,400 hospitals throughout the United States and associated areas. Data are collected on a variety of topics including hospital organizational structure, facilities and services, physician arrangements, staffing, and community orientation.

Antibiotic Stewardship Program

Hospital-based program intended to increase appropriate antibiotic use and reduce microbial resistance. Antibiotic stewardship is measured using data from the NHSN Patient Safety Component Annual Hospital Survey and data are included in annual quality improvement reports as an inpatient measure. CAHMPAS values reflect only data submitted by the March 31 NSHN deadline.

CAHMPAS

Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS) is a tool that contains data about Critical Access Hospitals’ (CAHs) performance on financial, quality, and community impact measures

CDC

The Centers for Disease Control and Prevention is a federal organization within the U.S. Department of Health and Human Services (HHS)

CMS

The Centers for Medicare and Medicaid Services (CMS) is a federal agency under the U.S. Department of Health and Human Services (HHS)

County Health Rankings and Roadmaps

The County Health Rankings and Roadmaps program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The goals of the program are to build awareness of the multiple factors that influence health; provide a reliable, sustainable source of local data and evidence to communities to help them identify opportunities to improve their health; engage and activate local leaders from many sectors in creating sustainable community change; and connect & empower community leaders working to improve health.

FMT

The Flex Monitoring Team (FMT) is a consortium of rural health researchers at the University of Minnesota, the University of North Carolina, and the University of Southern Maine

HAI

Healthcare Associated Infections (HAIs) are infections that patients acquire in a healthcare facility while receiving treatment for another condition or disease.

HCAHPS

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a patient satisfaction survey conducted by hospitals in the United States and is developed by CMS

Hospital Compare

Hospital Compare is a Medicare website that contains data for hospitals on various quality measures

HRSA

The Health Resources and Services Administration (HRSA) is a federal agency under the U.S. Department of Health and Human Services.

MBQIP

The Medicare Beneficiary Quality Improvement Program (MBQIP) is a quality improvement activity under the Flex program with the goal to improve quality of care provided by Critical Access Hospitals.

Medicare Hospital Cost Reports

Medicare-certified institutional providers are required to submit an annual cost report to a Medicare Administrative Contractor. The cost report contains provider information such as facility characteristics, utilization data, costs and charges by cost center (in total and for Medicare), Medicare settlement data, and financial statement data. CMS maintains the cost report data in the Healthcare Provider Cost Reporting Information System (HCRIS). View the CMS website.

NHSN

The National Healthcare Safety Network (NHSN) is a healthcare-associated infection (HAI) reporting system under the CDC. Facilities can use NHSN data to track HAIs, evaluate HAI prevention efforts, and fulfill mandated HAI reporting requirements. The CDC produces annual national and state HAI progress reports using the data submitted to NHSN.

SIR

Standardized infection ratio (SIR) compares the number of reported infections during a specified time period to the number of predicted infections for that same time period. A lower SIR is a better performance and a SIR of less than one indicates that there were fewer infections that predicted.

Behavioral Health

Inpatient psychiatric services

Percentage of CAHs that provide one or more of the following: (1) acute or long-term care to emotionally disturbed patients, including patients admitted for diagnosis and those admitted for treatment of psychiatric problems, on the basis of physicians’ orders and approved nursing care plans. Long-term care may include intensive supervision to the chronically mentally ill, mentally disordered, or other mentally incompetent persons; (2) care to emotionally disturbed children and adolescents, including those admitted for diagnosis and those admitted for treatment; and (3) care to emotionally disturbed elderly patients, including those admitted for diagnosis and those admitted for treatment.

Outpatient psychiatric services

Percentage of CAHs that provide one or more of the following: (1) psychiatric outpatient services including diagnosis and treatment of psychiatric outpatients; (2) psychiatric intensive outpatient services in which the patient receives outpatient care no less than three times a week (which might include more than one service/day); (3) psychiatric emergency services available on a 24-hour basis to provide immediate unscheduled outpatient care, diagnosis, evaluation, crisis intervention, and assistance to persons suffering acute emotional or mental distress; and (4) psychiatric partial hospitalization services for adult and/or pediatric patients including intensive day/evening outpatient services of three hours or more duration, distinguished from other outpatient visits of one hour.

Other psychiatric services

Percentage of CAHs that provide (1) psychiatric consultation/liaison services to non-psychiatric hospital staff and/or departments on psychological aspects of medical care that may be generic or specific to individual patients; and/or (2) psychiatric educational services to community agencies and workers such as schools, police, courts, public health nurses, welfare agencies, and clergy, in order to expand the mental health knowledge and competence of personnel not working in the mental health field and to promote good mental health through improved understanding, attitudes, and behavioral patterns.

Inpatient alcoholism/chemical dependency services

Percentage of CAHs that provide (1) diagnosis and therapeutic services to adult patients with alcoholism or other drug dependencies; and/or (2) diagnosis and therapeutic services to pediatric patients with alcoholism or other drug dependencies. These services include inpatient and/or residential treatment for patients whose course of treatment involves more intensive care than provided in an outpatient setting or where patients require supervised withdrawal.

Outpatient alcoholism/chemical dependency services

Percentage of CAHs that provide (1) medical care and/or rehabilitative treatment services to outpatients for whom the primary diagnosis is alcoholism or other chemical dependency; and/or (2) partial hospitalization services which are intensive day/evening outpatient services of three hour or more duration, distinguished from other outpatient visits of one hour.

Integrated behavioral health services

Percentage of CAHs that provide one or more of the following: (1) emergency services integrated with behavioral health care; (2) primary care services integrated with behavioral health care; (3) acute inpatient care integrated with behavioral health care; and (4) extended care integrated with behavioral health care.

Charity Care and Bad Debt

Charity care

Average cost of charity care as a percentage of adjusted revenue.

Bad debt

Average cost of non-Medicare and non-reimbursable Medicare bad debt as a percentage of adjusted revenue.

Uncompensated care

Average cost of uncompensated care as a percentage of adjusted revenue (includes both the average costs of charity care and the average costs of non-Medicare and non-reimbursable Medicare bad debt).

Medicaid/CHIP shortfall

Average unreimbursed cost of Medicaid, CHIP, and state and local indigent care programs as a percentage of adjusted revenue.

Emergency Medical Services

Ambulance services

Percentage of CAHs that provide ambulance services to the ill and injured who require medical attention on a scheduled or unscheduled basis.

Certified trauma centers

Percentage of CAHs certified to provide emergency and specialized intensive care to critically ill and injured patients.

Environmental Issues

Exercise opportunities

Percentage of population with adequate access to locations for physical activity.

Limited access to healthy foods

Percentage of population who are low-income and do not live close to a grocery store.

Food environment index

Index of factors that contribute to a healthy food environment, 0 (worst) to 10 (best).

Severe housing problems

Percentage of households with at least 1 of 4 housing problems: overcrowding, high housing costs, or lack of kitchen or plumbing facilities.

Health Behaviors

Adult smoking

Percentage of adults who are current smokers.

Adult obesity

Percentage of adults that report BMI ≥ 30.

Physical inactivity

Percentage of adults ages 20 and over reporting no leisure time physical activity.

Sexually transmitted infection rate

Number of newly diagnosed chlamydia cases per 100,000 population.

Teen birth rate

Number of births per 1,000 female population, ages 15-19.

Excessive drinking

Percentage of adults reporting binge or heavy drinking.

Motor vehicle crash death rate

Number of motor vehicle crash deaths per 100,000 population.

Alcohol-impaired driving deaths

Percentage of driving deaths with alcohol involvement.

Injury death rate

Number of deaths due to injury per 100,000 population.

Drug overdose mortality rate

Number of deaths due to drug poisoning per 100,000 population.

Homicide rate

Number of deaths from assaults, defined as ICD-10 codes X85-Y09, per 100,000 population.

Firearm fatality rate

Number of deaths due to firearms, defined as ICD-10 codes W32-W34, X72-X74, X93-X95, Y22-Y24, and Y35.0, per 100,000 population.

Violent crime rate

Number of reported violent crime offenses per 100,000 population

Health Outcomes

Premature death

Years of potential life lost before age 75 per 100,000 population, age adjusted.

Child mortality

Number of deaths among children under age 18 per 100,000 population.

Infant mortality

Number of deaths among children less than one year of age per 1,000 live births.

Diabetes prevalence

Percentage of adults diagnosed with diabetes.

Poor or fair health

Percentage of adults reporting poor or fair health, age adjusted.

Low birth weight

Percentage of live births with low birthweight, < 2500 grams.

Physically unhealthy days

Average number of physically unhealthy days reported in the past 30 days, age-adjusted.

Poor mental health days

Average number of mentally unhealthy days reported in past 30 days, age-adjusted.

Long Term Services and Supports

Skilled nursing care

Percentage of CAHs that provide non-acute medical and skilled nursing care services, therapy, and social services under the supervision of a licensed registered nurse on a 24-hour basis.

Intermediate nursing care

Percentage of CAHs that provide health-related services (skilled nursing care and social services) to residents with a variety of physical conditions or functional disabilities. These residents do not require the care provided by a hospital or skilled nursing facility, but do need supervision and support services.

Other long term care

Percentage of CAHs that provide long term care other than skilled nursing or intermediate care. This can include residential care-elderly housing services for those who do not require daily medical or nursing services, but may require assistance in the activities of daily living, or sheltered care facilities for developmentally disabled.

Adult day care programs

Percentage of CAHs that provide supervision, medical and psychological care, and social activities for older adults who live at home or in another family setting, but cannot be alone or prefer to be with others during the day. May include intake assessment, health monitoring, occupational therapy, personal care, noon meal, and transportation services.

Home health services

Percentage of CAHs providing nursing, therapy, and health-related homemaker or social services in the patient’s home.

Palliative care

Percentage of CAHs that provide (1) physically discreet, inpatient palliative care units where palliative medicine specialists provide symptom relief for complex patients who may be continuing to undergo primary treatment; and/or (2) organized hospital programs offering specialized medical care, drugs or therapies for the management of acute or chronic pain and/or the control of symptoms, and supportive care services such as counseling on advanced directives, spiritual care, and social services, to patients with advanced disease and their families.

Hospice programs

Percentage of CAHs that provide palliative care, chiefly medical relief of pain and supportive services addressing the emotional, social, financial, and legal needs of terminally ill patients and their families. Care can be provided in a variety of settings, both inpatient and at home.

Other Health Care Services

Obstetrics

Percentage of CAHs providing care, examination, treatment, and other services to women during pregnancy, labor, and the puerperium.

Dental services

Percentage of CAHs with an organized dental service or dentists on staff, not necessarily involving special facilities, providing dental or oral services to inpatients or outpatients.

Telehealth services

Percentage of CAHs that provide one or more of the following: (1) telehealth consultation and office visits; (2) electronic intensive care unit services; (3) stroke telemedicine; (4) telehealth psychiatric and addiction treatment; (5) telehealth remote patient monitoring post-discharge; and (6) telehealth remote patient monitoring for ongoing chronic care management.

Primary Care

Indigent care clinics

Percentage of CAHs with indigent care clinics that provide health care services for uninsured and underinsured persons free of charge or charged on a sliding scale. This includes free clinics staffed by volunteer practitioners and clinics staffed by employees with the sponsoring health care organization subsidizing the cost of service.

Rural Health Clinics

Percentage of CAHs with Rural Health Clinics (RHCs). RHCs are located in rural, medically under-served areas and receive enhanced reimbursement under the Medicare and Medicaid programs.

Urgent care clinics

Percentage of CAHs that provide care and treatment for problems that are not life threatening but require attention over the short term. These units function like emergency rooms but are separate from hospitals with which they may have backup affiliation arrangements.

Provider Supply and Access to Care

Primary care physicians

Ratio of population to primary care physicians.

Other primary care providers

Ratio of population to other primary care providers (other than physicians) including nurse practitioners, physician assistants, and clinical nurse specialists.

Mental health providers

Ratio of population to mental health providers.

Dentists

Ratio of population to dentists.

Uninsured

Percentage of population under age 65 without health insurance.

Mammography screening

Percentage of female Medicare enrollees ages 65-74 that receive mammography screening. For 2017 and 2018, this measure shows the percentage of female Medicare enrollees ages 67-69 that receive mammography screening.

Diabetes monitoring

Percentage of diabetic Medicare enrollees ages 65-75 that receive HbA1c monitoring. This measure was discontinued by County Health Rankings and Roadmaps in 2019.

Preventable hospital stays

Number of hospital stays for ambulatory-care sensitive conditions per 100,000 Medicare enrollees. The numerator is the number of discharges for Medicare beneficiaries ages 18 years or older continuously enrolled in Medicare fee-for-service Part A and hospitalized for any of the following reasons: diabetes with short or long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, dehydration, bacterial pneumonia, or urinary tract infection. The denominator is the Medicare beneficiaries ages 18 years or older continuously enrolled in Medicare fee-for-service Part A.

For 2017 and 2018, the numerator for this measure is the number of discharges, for Medicare fee-for-service enrollees ages 18 and older, hospitalized for any of the following reasons: Convulsions, Chronic Obstructive Pulmonary Disease, Bacterial Pneumonia, Asthma, Congestive Heart Failure, Hypertension, Angina, Cellulitis, Diabetes, Gastroenteritis, Kidney/Urinary Infection, and Dehydration. The denominator for 2017 and 2018 is 100% of Medicare enrollees with full Part A entitlement and no HMO enrollment during the measurement period in the county.

Socioeconomic Factors

High school graduation

Percentage of the ninth-grade cohort that graduates in four years.

Unemployment

Percentage of the population age 16 and older unemployed but seeking work.

Children in poverty

Percentage of children under age 18 in poverty.

Median household income

Income where half of households earn more and half of households earn less.

Income inequality

Ratio of household income at the 80th percentile to income at the 20th percentile. A higher inequality ratio indicates greater division between the top and bottom ends of the income spectrum.

Population under age 18

Percentage of the population below 18 years of age.

Population 65 and older

Percentage of population age 65 and older.

Wellness and Prevention

Immunization programs

Percentage of CAHs with an immunization program that plans, coordinates and conducts immunization services in the community.

Tobacco treatment/cessation programs

Percentage of CAHs providing organized hospital services with the purpose of ending tobacco-use habits of patients addicted to tobacco/nicotine.

Enrollment assistance programs

Percentage of CAHs that provide enrollment assistance for patients who are potentially eligible for public health insurance programs such as Medicaid, State Children’s Health Insurance, or local/state indigent care programs. The specific services offered could include explanation of benefits, assist applicants in completing the application and locating all relevant documents, conduct eligibility interviews, and/or forward applications and documentation to state/local social service or health agencies.

Diabetes prevention programs

Percentage of CAHs with diabetes prevention programs designed to prevent or delay the onset of type 2 diabetes by offering evidence-based lifestyle changes based on research showing modest behavior change can help individuals with prediabetes reduce their risk of developing type 2 diabetes.

Financial indicators definitions and interpretations can be found below.

View Financial Indicators

For more detailed information about these indicators, please visit the Financial data portal.

CAUTI

A catheter-associated urinary tract infection (CAUTI) is an infection of the bladder, kidneys, ureters, urethra, or any other part of the urinary system that are associated with the use of a catheter. CAUTIs are measured using SIRs with the reported number of CAUTIs annually as the numerator and the predicted number of infections as the denominator.

CDI

A Clostridium difficile infection (CDI), also known as C. diff, is a bacterial infection resulting in diarrhea caused by difficile bacterium. CDIs are measured using SIRs with the reported number of CDIs annually as the numerator and the predicted number of infections as the denominator.

CLABSI

A central line-associated bloodstream infection (CLABSI) is a bloodstream infection in a patient with a central line. CLABSIs are measured using SIRs with the reported number of CLABSIs annually as the numerator and the predicted number of infections as the denominator.

ED-1b

Admit Decision Time to Emergency Department (ED) Departure Time for Admitted Patients – median time from admit decision time to time of departure from the ED for patients admitted to inpatient status. (A lower number is better.)

ED-2b

Median Time from Emergency Department (ED) Arrival to ED Departure for Admitted Patients -median time from ED arrival to time of departure from the ED for patients admitted to the facility from the ED (A lower number is better.)

HCAHPS Measures

HCAHPS Composite 1

Nurse always communicated well

HCAHPS Composite 2

Doctors always communicated well

HCAHPS Composite 3

Patient always received help as soon as wanted

HCAHPS Composite 4

Patient felt pain was always well-controlled (Removed in 2017)

HCAHPS Composite 5

Staff always explained medications before giving them to patient

HCAHPS Composite 6

Staff provided information about what to do after discharge during recovery at home

HCAHPS Composite 7

Patient strongly agreed that they understood their care when they left the hospital

Question 8

Patient’s room and bathroom were always clean

Question 9

Area around patient’s room was always quiet at night

Question 18

Patient gave a rating of 9 or 10 (high) on a 1 – 10 scale. Prior to 2020, this was question 21.

Question 19

Patient would definitely recommend hospital to friends and family. Prior to 2020, this was question 22.

HCP / IMM-3

Health Care Workers Given Influenza Vaccination – Facilities must report vaccination data for three categories of Healthcare Personnel (HCP): employees on payroll; licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the hospital and not on payroll); and students, trainees, and volunteers aged 18 or older. Only HCP physically working in the facility for at least one day or more between October 1 and March 31 should be counted. Data on vaccinations received at the facility, vaccinations received outside of the facility, medical contraindications, and declinations are reported for the three categories of HCP.

IMM-2

Influenza Vaccination – This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated. The numerator captures two activities: screening and the intervention of vaccine administration when indicated. As a result, patients who had documented contraindications to the vaccine, patients who were offered and declined the vaccine, and patients who received the vaccine during the current year’s influenza season but prior to the current hospitalization are captured as numerator events.

MOU

A memorandum of understanding (MOU) is required for CAHs to share their data through the MBQIP program.

MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a type of bacterial infection that are resistant to common antibiotics and can infect many parts of the human body. MRSA infections can occur in patients several ways including after surgery or after the placement of intravenous tubing. MRSA infections are measured using SIRs with the reported number of MRSA infections annually as the numerator and the predicted number of infections as the denominator.

OP-1

Median Time to Fibrinolysis – median time from arrival to fibrinolysis for patients that received fibrinolysis. (A lower number is better.)

OP-2

Fibrinolytic therapy received within 30 minutes of arrival – Acute Myocardial Infarction (AMI) patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.

OP-3b

Median Time to Transfer to Another Facility for Acute Coronary Intervention – Median number of minutes before outpatients with heart attack who needed specialized care were transferred to another hospital. (A lower number is better.)

OP-4

Aspirin at arrival – Acute Myocardial Infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.

OP-5

Median Time to echocardiogram (ECG) – median number of minutes before outpatients with heart attack (or with chest pain that suggests a possible heart attack) got an ECG. (A lower number is better).

OP-12

Ability to Receive Lab Data Directly to Electronic Health Record (EHR) – the ability for providers with Health Information Technology (HIT) to receive laboratory data directly into their ONC-certified EHR system as discrete searchable data.

OP-17

Ability to Track Clinical Results between Visits – the ability for a facility to track pending laboratory tests, diagnostic studies, or patient referrals through the ONC-certified Electronic Health Record (EHR) system.

OP-18b

Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged Patients – median time from ED arrival to time of departure from the ED for patients discharged from the ED. (A lower number is better).

OP-20

Door to Diagnostic Evaluation by Qualified Medical Personnel – median time from Emergency Department (ED) arrival to provider contact for ED patients. (A lower number is better).

OP-21

Median Time to Pain Management for Long Bone Fracture – median time from Emergency Department (ED) arrival to time of initial oral or parenteral pain medication administration for ED patients with a principal diagnosis of long bone fracture. (A lower number is better).

OP-22

Left Without Being Seen – percent of patients who leave the Emergency Department (ED) without being evaluated by a physician, advanced practice nurse (APN), or physician’s assistant (PA). (A lower number is better.)

OP-23

Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Emergency Department (ED) Arrival – percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within 2 hours of the onset of symptoms who have a head CT or MRI scan performed during the stay and have interpretation of the CT or MRI scan within 45 minutes of arrival.

OP-25

Use of Safe Surgery Checklist (Outpatient) – whether or not a facility used a checklist for outpatient surgical procedures during each of the three critical perioperative periods (prior to administration of anesthesia, prior to skin incision, and closure of incision / prior to patient leaving the operating room).

OP-29

Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients – Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

OP-30

Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or more years since their last colonoscopy.

PC-01

Elective Delivery – patients with elective vaginal deliveries or elective cesarean sections at greater than or equal to 37 and less than 39 weeks of gestation completed. (A lower number is better).

SM-HS-PATIENT-SAF

Use of hospital survey on patient safety culture.

SM-PART-GEN-SURG (SM-4)

General Surgery Registry – participation in a systematic clinical database for general surgery. (Removed in 2017)

SM-PART-NURSE (SM-3)

Nursing Care Registry – participation in a systematic clinical database for nursing-sensitive care. (Removed in 2017)

SM-SS-CHECK (SM-5)

Use of Safe Surgery Checklist (inpatient) – whether or not a facility used a checklist for inpatient surgical procedures during each of the three critical perioperative periods (prior to administration of anesthesia, prior to skin incision, and closure of incision / prior to patient leaving the operating room).

SSI:C

A surgical site infection from colon surgery (SSI:C) is an infection that occurs in patients after they have colon surgery. SSI:C infections are measured using SIRs with the reported number of SSI:C infections annually as the numerator and the predicted number of infections as the denominator.

SSI:H

A surgical site infection from abdominal hysterectomy (SSI:H) is an infection that occur in patients after they have abdominal hysterectomies. SSI:H infections are measured using SIRs with the reported number of SSI:H infections annually as the numerator and the predicted number of infections as the denominator.

STK-4

Thrombolytic Therapy – acute ischemic stroke patients who arrive at this hospital within two hours of time last known well and for whom intravenous tissue plasminogen activator (IV tPA) was initiated at this hospital within three hours of time last known well. (Removed in 2017)

VTE-5

Venous Thromboembolism (VTE) Warfarin Therapy Discharge Instructions – the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. (Removed in 2017)

VTE-6

Hospital Acquired Potentially-Preventable Venous Thromboembolism (VTE) – the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. (A lower number is better).