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IRF Quality Reporting Measures Information

The purpose of this page is to provide information on the measures that are to be reported by IRFs in accordance with the IRF QRP. On this page, you will find measure titles, National Quality Forum (NQF) identification number, if applicable, and final rule information. This page is updated as measure updates become available.

For more detailed information on data collection and submission deadlines, please refer to the IRF Quality Reporting Data Submission Deadlines webpage. For more information on the data sets and quality reporting requirements, please reference the IRF-PAI V 1.5 and Section 4,the Quality Indicator section of the IRF Training Manual, located on the IRF-PAI and IRF QRP Manual webpage .

What are the Inpatient Rehabilitation Facilities (IRF) quality reporting measures?

Measures currently adopted and finalized for the IRF QRP are listed below. Data for the IRF QRP measures are collected and submitted through three methods:

  • Inpatient Rehabilitation Facility – Patient Assessment Instrument ( IRF-PAI)
  • Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
  • Medicare Fee-For-Service Claims

The following measures are submitted using the IRF-PAI unless noted otherwise: 

IRF Measure #1:  Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

An application of this measure was finalized in the FY 2012 IRF PPS Final Rule which was published in the Federal Register on 08/05/2011 (76 FR 47874).  The NQF-endorsed risk adjusted version of the measure was adopted in the FY 2014 IRF PPS Final Rule which was published in the Federal Register on 08/06/2013 (78 FR 47902). Data collection for this measure began on 10/01/2012.   As finalized in the FY 2018 IRF PPS Final Rule which was published in the Federal Register on 08/03/2017 (82 FR 36277), this measure will be replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 IRF QRP.       

IRF Measure #2: National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)

Use of a previous version of this measure was finalized in the FY 2012 IRF PPS Final Rule which was published in the Federal Register on 08/05/2011 (76 FR 47874).   The updated version of the CAUTI measure was adopted in the CY 2013 Hospital Outpatient Prospective Payment System Final Rule which was published in the Federal Register on November 15, 2012 (77 FR 68500).  Data collection for this measure began on 10/01/2012. The data for this measure is submitted via CDC/NHSN.

IRF Measure #3: Influenza Vaccination among Healthcare Personnel (NQF #0431).

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). Data collection for this measure began on 10/01/2014. The data for this measure is submitted via CDC/NHSN.

IRF Measure #4:  Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680). 

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). Data collection for this measure began on 10/01/2014.

IRF Measure #5:  All Cause Unplanned 30 day post IRF Discharge Readmission Measure. 

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). This is a claims-based measure and no additional data need to be submitted by the IRF. As finalized in the FY 2018 IRF PPS Final Rule which was published in the Federal Register on 08/03/2017 (82 FR 36283), this measure will be removed beginning with the FY 2019 IRF QRP.   

IRF Measure #6:  NHSN Facility-wide Inpatient Hospital-onset Methicillin resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716).

This measure was finalized in the FY 2015 IRF Final Rule which was published in the Federal Register on August 6, 2014 (79 FR 45872). Data collection for this measure began 01/01/2015. The data for this measure is submitted via CDC/NHSN. 

IRF Measure #7:  NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717).

This measure was finalized in the FY 2015 IRF Final Rule which was published in the Federal Register on August 6, 2014 (79 FR 45872). Data collection for this measure began 01/01/2015. The data for this measure is submitted via CDC/NHSN. 

IRF Measure #8:  Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47100). Data collection for this measure began 10/1/2016.

IRF Measure #9:  Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47111). Data collection for this measure began 10/1/2016.

IRF Measure #10:  IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47117). Data collection for this measure began 10/1/2016.

IRF Measure #11:  IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47118). Data collection for this measure began 10/1/2016.

IRF Measure #12:  IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47119). Data collection for this measure began 10/1/2016.

 IRF Measure #13:  IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636).

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47120). Data collection for this measure began 10/1/2016.

IRF Measure #14: Medicare Spending per Beneficiary (MSPB)–PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #15: Discharge to Community–PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measures #16: Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #17: Potentially Preventable Within Stay Readmission Measure

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #18: Drug regimen Review Conducted with Follow-Up for Identified Issues – PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52111). Data collection for this measure will begin 10/1/2018.

IRF Measure #19: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 IRF PPS Final Rule which was published on August 3, 2017 (82 FR 36277). Data collection for this measure will begin 10/1/2018 using data elements that already exist on the IRF-PAI.

Archives

IRF Measures Information Archives

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