Measures

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

CDC and CMS Joint Reminder on NHSN Reporting

The Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) is the nation’s most comprehensive medical event tracking system. It is currently utilized by more than 16,000 U.S. healthcare facilities. NHSN provides critical data that guides prevention efforts aimed at protecting patients.

CDC and the Centers for Medicare & Medicaid Services (CMS) are committed to ensuring the accuracy of data used to set prevention priorities and protect patients. Identifying infections and infection sources, as well as guaranteeing that patients receive the highest quality of care are the top priorities of both agencies.

In response to anecdotal reports of intentional non-reporting of infection data, CDC and CMS have jointly issued a reminder that addresses the importance of reporting healthcare-associated infection events. While there is no evidence of a widespread issue, CDC and CMS want to emphasize that accurate reporting to NHSN through strict adherence to NHSN definitions and criteria is essential to ensuring accuracy, completeness, and comparability of infection information.

Download the full reminder (PDF-300 KB) or read more about NHSN reporting on the CDC website.

Measure Requirements

Hospitals participating in the PCHQR Program are required to report the following measures according to the specified program year reporting requirements as outlined in the current and prior releases of the Final Rules.

Refer to the Data Collection page for measure specifications. Refer to the Data Submission page for submission deadlines. Refer to the Measure Crosswalk for an accessible, print-friendly version of the information displayed below.

Finalized measures for inclusion in the PCHQR Program (by measure type and program year)

Table 1: Safety and Healthcare-Associated Infection (HAI) Measures

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
0138 PCH-5 CDC NHSN Catheter-Associated Urinary Tract Infections (CAUTI) Outcome Measure Y Y Y Y Y

Y

Y
0139 PCH-4 CDC NHSN Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure Y Y Y Y Y Y Y
0753 PCH-6 and PCH-7 Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure Y Y Y Y Y Y Y
0431 PCH-28 CDC NHSN Influenza Vaccination Coverage Among Healthcare Personnel (HCP) N/A N/A N/A Y Y Y Y
1716 PCH-27 CDC NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylocccus aureus (MRSA) Bacteremia Outcome Measure N/A N/A N/A Y Y Y Y
1717 PCH-26

CDC NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure

N/A N/A N/A Y Y Y Y

Table 2: Clinical Process/Cancer-Specific Treatment Measures

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
0223 PCH-1 Adjuvant Chemotherapy is Considered or Administered Within 4 Months (120 days) of Diagnosis to Patients Under the Age of 80 with AJCC III (lymph node positive) Colon Cancer Y Y Y Y N/A N/A N/A
0559 PCH-2 Combination Chemotherapy is Considered or Administered Within 4 Months (120 days) of Diagnosis for Women Under 70 with AJCC T1c, or Stage IB-III Hormone Receptor Negative Breast Cancer Y Y Y Y N/A N/A N/A
0220 PCH-3 Adjuvant Hormonal Therapy Y Y Y Y N/A N/A N/A

Table 3: Clinical Process/Oncology Care Measures (OCM)

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
0382 PCH-14 Oncology: Radiation Dose Limits to Normal Tissues N/A Y Y Y Y Y N/A
0383 PCH-15 Oncology: Plan of Care for Pain – Medical Oncology and Radiation Oncology (paired with 0384) N/A Y Y Y Y Y Y
0384 PCH-16 Oncology: Medical and Radiation - Pain Intensity Quantified N/A Y Y Y Y Y N/A
0390 PCH-17 Prostate Cancer: Adjuvant Hormonal Therapy for High and Very High Risk Prostate Cancer Patients N/A Y Y Y Y Y N/A
0389 PCH-18 Prostate Cancer: Avoidance of Overuse Measure - Bone Scan for Staging Low Risk Prostate Cancer Patients N/A Y Y Y Y Y N/A
0210 PCH-32 Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life N/A N/A N/A N/A N/A Y Y
0215 PCH-34 Proportion of Patients Who Died of Cancer Not Admitted to Hospice N/A N/A N/A N/A N/A Y Y

Table 4: Intermediate Clinical Outcome Measures

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
0213 PCH-33 Proportion of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life N/A N/A N/A N/A N/A Y Y
0216 PCH-35 Proportion of Patients Who Died from Cancer Admitted to Hospice for Less Than Three (3) Days N/A N/A N/A N/A N/A Y Y

Table 5: Clinical Effectiveness Measure

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
N/A PCH-25 External Beam Radiotherapy for Bone Metastases N/A N/A Y Y Y Y Y

Table 6: Patient Engagement/Experience of Care Measure

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
0166 PCH-29 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey N/A Y Y Y Y Y Y

Table 7: Claims-Based Outcome Measure

Y = Applicable for stated program year; N/A = Not Applicable for stated program year

NQF # PCH # Measure Name FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021
N/A PCH-30 and PCH-31 Admissions and Emergency Department (E.D.) Visits for Patients Receiving Outpatient Chemotherapy N/A N/A N/A N/A Y Y Y
3188 N/A 30-Day Unplanned Readmissions for Cancer Patients N/A N/A N/A N/A N/A N/A Y

QualityNet requires Internet Explorer with JavaScript enabled on it.

Steps to enable JavaScript in Internet Explorer
  1. Click on the Tools menu option at the top of the page.
  2. Select Internet Options from the drop-down menu.
  3. From the dialog box, choose the Security tab.
  4. Click on Custom Level.
  5. Set Active Scripting to Enable.
  6. Click OK to close the custom settings dialog.
  7. Click OK to close the Options dialog.