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  1. eCQM Issue Tracker
  2. CQM-7410

CMS826 Workflow alignment and feedback

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your inquiry regarding CMS826v2, Hospital Harm – Pressure Injury. The measure’s Numerator offers flexibility in its timing requirements by looking for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries not present on admission (via present on admission (POA) indicators) or found by a skin exam any time after the initial 72 hours and 24 hours, respectively, from the start of the encounter. The measure’s Denominator Exclusions look for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries found by a skin exam within the initial 72 hours and 24 hours, respectively, from the start of the encounter. Additionally, the measure’s Denominator Exclusions look for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries present on admission via POA indicators. This is intended to accommodate hospital workflows or resource constraints that make it difficult to perform a skin exam within the first 24 to 72 hours of the encounter.
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      Thank you for your inquiry regarding CMS826v2, Hospital Harm – Pressure Injury. The measure’s Numerator offers flexibility in its timing requirements by looking for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries not present on admission (via present on admission (POA) indicators) or found by a skin exam any time after the initial 72 hours and 24 hours, respectively, from the start of the encounter. The measure’s Denominator Exclusions look for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries found by a skin exam within the initial 72 hours and 24 hours, respectively, from the start of the encounter. Additionally, the measure’s Denominator Exclusions look for deep tissue pressure injuries and stage 2, 3, 4, or unstageable pressure injuries present on admission via POA indicators. This is intended to accommodate hospital workflows or resource constraints that make it difficult to perform a skin exam within the first 24 to 72 hours of the encounter.
    • CMS0826v2
    • Increased burden to implement changes to workflow in order to get accurate results.

      Good Morning,

      Many of the hospitals we support who have implemented or are working on implementing this measure have provided feedback regarding challenges with accurate data capture in the required timeframes (per measure logic). Frequently, the protocol is for the wound care nurse to do the PI staging which is an issue for smaller hospitals that only have wound care nurses on staff part time, or only on weekdays (off weekends/nights).

      In these cases, the small, already burdened hospitals, are having to put new processes, workflow, documentation in place to capture the staging of the wound within the time constraints of the logic.

      Do you have any suggestions on how to address this to minimize burden on the hospital?

      Thank you. -Kristen

            aweber Mathematica EH eCQM Team
            kbeatson123 Kristen Beatson
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