Sign of the times…the potential (and confirmed) new eCQMS part 1

Sept. 9, 2019 / By Cheryl Manchenton, RN

I have to confess I am starting to show my age. When someone mentions sign of the times, I think of Petula Clark Sign of the times, not the Harry Styles song! Current healthcare issues and challenges often prompt changes to quality reporting (or potential ones) and these electronic Clinical Quality Measures (eCQMS) clearly point to the sign(s) of the times in health care.

The Final Rule for FY 2020 did not disappoint on this front and sent a  clear messages to healthcare organizations about where the focus on quality of care is heading.

Let’s start with an oldie but a goodie…pressure ulcers. The have long been a Hospital Acquired Condition (HAC) and have also been a Patient Safety Indicator (PSI) and a Potentially Preventable Complication (PPC). However, the Inpatient Quality Reporting Program (IQR) is now adding pressure ulcers to their list of eCQMs.

Per the Final Rule, an estimated 1.9 million hospital-acquired pressure injuries occurred in 2015. Furthermore, the presence or development of a pressure injury can increase the length of stay by an average of four days which can then result in an increase in spending ranging from $20,900 to $151,00 per pressure injury.1,2,3

Efforts to decrease the incidence of pressure injuries have proven successful, but CMS noted there is great variability in rates among healthcare organizations.  Hence, CMS believes pressure injuries should be addressed via the IQR program as well.

The proposal to monitor pressure ulcer incidence is via direct abstraction (not claims-based/administrative data as with HACs, PPCs and PSIs). Another significant difference is expansion of current reportable pressure injuries 3, 4, DTI and unstageable to include stage 2. This measure has received provisional support by the National Quality Forum (NQF) pending review and endorsement once the measure is fully tested. Although NQF made recommendations for exclusions of selected patients (end-of-life), as well as those with low albumins or other such clinical data, the measure in its current form is not risk-adjusted, as CMS noted most newly acquired injuries can be avoided via evidence-based care.

One additional nuance is the definition of hospital-acquired (also described as “newly-acquired”) includes those conditions not present within the first 24 hours of hospital arrival. This places a large burden on facilities to ensure the skin survey is completed within 24 hours of admission and that consistent application of descriptions of skin alterations be utilized (incontinence related dermatitis or breakdown compared to a pressure ulcer as an example).

Note: This is just a proposed eCQM, but it is moving through the NQF endorsement process and what remains to be determined surrounds populations (or excluded ones), reporting structures and logistics such as reporting multiple pressure ulcers or pressure ulcers that have progressed during the stay.

There are clear signs of the times and I would refer you to our October Quality Webinar on the FY2020 Final Rule changes impacting quality (current changes, not proposed).

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

Read part two and part three of the series.


1Gunningberg, L., Donaldson, N., Aydin, C. & Idvall, E. (2012). Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action. Journal of Evaluation in Clinical Practice,18: 904-910.

2Bauer, K., Rock, K., Nazzai, M. J., & Qu, W. (2016). Pressure Ulcers in the United States Inpatient Population from 20018 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Management, 62(11): 30-38.

3Agency for Healthcare Research and Quality. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. (2016). Available at: