Rural Hospital Quality Indicators for Public Reporting

The Rural Healthcare Center, CHA and CHART have been discussing the value of CHART determining which measures are appropriate for small volume hospitals to publically report via CHART.

The workgroup surveyed Critical Access Hospitals (CAHs) to determine the volume of specific patients treated in CAHs. The average daily census (ADC) for inpatient ranged from 2 to 32 with an average of 9 and the ADC for the emergency department ranged from 3 to 63 with the average daily census was 18. The total quarterly inpatient discharges was at least 26-50, whereas transfers from the hospital or ED were at least 7-10 per quarter.

CHA and CHART worked with a group of small volume hospital CEOs, chief nursing officers and quality directors to agree on the following measures. The Rural Healthcare Center, comprised of CEOs, will formally endorse these measures at the July 29 meeting.

In an effort to expedite the timeline and meet the California Department of Public Health Rural Flex Grant deadline of recruiting 10 rural hospitals into CHART by August 30, 2009, the CHA Rural Healthcare Center, along with CHA, is making the following proposal for rural CHART measures.


Any hospital designated as a state or federal rural hospital shall be eligibility to participate in the rural CHART measures.

All hospitals with sufficient sample size shall submit data for CHART measures in addition to the rural measures with the following exceptions. This excludes pressure ulcers until such time as the California Nursing Outcomes (CalNOC) makes a determination that there is an accurate way to publicly report HAPU for small volume hospitals. This should also exclude the administrative measures until validation studies for small volume hospitals show that these are valid measures.

Sample size threshold below which a hospital would not collect data

CHA and the Rural Center are requesting that CHART determine the smallest acceptable sample size for each CHART measure. The Joint Commission and the Centers for Medicare and Medicaid (CMS) use 25 or 30 cases per reporting period. Hospitals should not be required to report data for measures that consistently have a sample size below this threshold.

Reporting Period

CHART typically uses a quarterly reporting system. It may be appropriate to use an every six months reporting period for small volume hospitals to ensure adequate sample size.


Emergency Department Chest Pain/AMI

  • Median time from arrival in ED to ECG for patients treated in ED and/or transferred (CMS and OPPS Rule)
  • Aspirin on arrival (CMS and OPPS Rule)
  • Median time to thrombolytics from arrival in ED for patients treated then transferred (CMS and OPPS Rule)
  • Median time from ED arrival to transfer for primary percutaneous coronary intervention (CMS and OPPS) -(Sample size may be too small).

Transfer from ED or Inpatient to another Facility (from the flex monitoring team report)

  • RN communication with receiving hospital RN/staff
  • Physician communication with receiving physician
  • Patient Information (fact-sheet):
    • Name
    • Address
    • Age
    • Gender
    • Contact Information
    • Insurance Information
  • Diagnosis/Indicator
    • Pulse
    • Respiration
    • Blood pressure
    • Temperature
    • Pulse O2 level
    • Glasgow score
    • Apgar score (if applicable)
  • Medication history (Med Reconciliation)
  • Medications Given (MAR)
  • AllergiesPhysician’s history and physical
  • Physician’s orders and reason for transfer
  • Nurse documentation:
    • Assessment
    • Interventions/response
  • Tests and procedures done (copies as indicated)


  • Appropriate empiric antibiotic prescribed for community-acquired bacterial pneumonia (CMS)
  • Patients aged 65+ screened for pneumococcal vaccine and were administered Pneumovax before discharge, if indicated (CMS)
  • Patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. (CMS)
  • Patients who were transferred or admitted to the intensive care unit (ICU) or to hospital within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival.(CMS)
  • Patient with oxygen saturation assessed (CMS)
  • Patients who received smoking cessation intervention (CMS)
  • Patients who receive their first dose of antibiotic within 6 hours of arriving at hospital (CMS)
  • Time to antibiotic after first arriving to hospital (CMS)
  • Patients whose initial ED blood culture specimen was collected prior to first hospital dose of antibiotics. (CMS)

Heart Failure

  • Adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her caregiver at discharge or during the hospital stay, addressing all of the following:
    • activity level
    • diet
    • discharge medications
    • follow-up appointment
    • weight monitoring, and
    • what to do if symptoms worsen (CMS)
  • ASA on Discharge (CMS)
  • Patients with documented Left Ventricular Systolic (LVS) Function (CMS)
  • Angiotensin-converting enzyme inhibitor(s )(ACEI) or ARB for Left Ventricular Systolic Dysfunction (LVSD) (CMS)
  • Adult Smoking Cessation Advice/Counseling (CMS)