Measures
Hospital-Acquired Condition Reduction Program Measures
The Centers for Medicare & Medicaid Services (CMS) first adopted the measures and scoring methodology for the Hospital-Acquired Condition (HAC) Reduction Program in the fiscal year (FY) 2014 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule. In the FY 2017 IPPS/LTCH PPS final rule, CMS adopted the modified version of the CMS Patient Safety and Adverse Events Composite (CMS PSI 90) measure.
The HAC Reduction Program currently includes six measures:
- One claims-based composite measure of patient safety: CMS PSI 90
- Five chart-abstracted or laboratory-identified measures of healthcare-associated infections (HAIs) submitted to the Centers for Disease Control and Prevention’s (CDC's) National Healthcare Safety Network (NHSN):
- Central Line-Associated Bloodstream Infection (CLABSI)
- Catheter-Associated Urinary Tract Infection (CAUTI)
- Colon and Abdominal Hysterectomy Surgical Site Infection (SSI)
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
- Clostridium difficile Infection (CDI)
The following table displays the measures’ performance periods for the FY 2015 to FY 2027 program years.
| Program Year | CMS PSI 90 Measure | CDC's NHSN HAI Measures |
|---|---|---|
| FY 2027 | 7/1/23 to 6/30/25 | 1/1/24 to 12/31/25 |
| FY 2026 | 7/1/22 to 6/30/24 | 1/1/23 to 12/31/24 |
| FY 2025 | 7/1/21 to 6/30/23 | 1/1/22 to 12/31/23 |
| FY 2024 | 1/1/21 to 6/30/22a | 1/1/22 to 12/31/22b |
| FY 2023 | N/Ac | 1/1/21 to 12/31/21a,d |
| FY 2022 | 7/1/18 to 12/31/19a | 1/1/19 to 12/31/19a |
| FY 2021 | 7/1/17 to 6/30/19 | 1/1/18 to 12/31/19 |
| FY 2020 | 7/1/16 to 6/30/18 | 1/1/17 to 12/31/18 |
| FY 2019 | 10/1/15 to 6/30/17e | 1/1/16 to 12/31/17 |
| FY 2018 | 7/1/14 to 9/30/15e, f | 1/1/15 to 12/31/16 |
| FY 2017 | 7/1/13 to 6/30/15 | 1/1/14 to 12/31/15 |
| FY 2016 | 7/1/12 to 6/30/14 | 1/1/13 to 12/31/14 |
| FY 2015 | 7/1/11 to 6/30/13 | 1/1/12 to 12/31/13 |
a CMS automatically excluded all claims data representing CY 2020 data from all program calculations for the HAC Reduction Program (quarter [Q]1 and Q2 2020 claims were excluded as a result of the nationwide ECE announced on March 27, 2020; Q3 and Q4 2020 were excluded as finalized in the FY 2022 IPPS/LTCH PPS final rule [pages 45301-45307]).
b CMS automatically excluded all CY 2021 HAI data from FY 2024 program calculations for the HAC Reduction Program, as finalized in the FY 2023 IPPS/LTCH PPS final rule (pages 49130‒49132).
c CMS paused use of the CMS PSI 90 measure in the FY 2023 HAC Reduction Program, as finalized in the FY 2023 IPPS/LTCH PPS final rule (pages 49121‒49130), in response to the COVID-19 public health emergency.
d CMS did not calculate measure scores for any hospital for the FY 2023 program year, as finalized in the FY 2023 IPPS/LTCH PPS final rule (pages 49121‒49130). CMS calculated and publicly reported HAI standardized infection ratios (SIRs; that is, measure results) for the FY 2023 program year.
e This performance period for CMS PSI 90 was shortened because of the transition from the 9th to 10th edition of the International Classification of Diseases.
f CMS adopted the modified version of the CMS PSI 90 measure in FY 2018.
Additional Resources
IPPS Measure Exception Forms
Some hospitals could be eligible for an exception from reporting requirements for some of the CDC’s NHSN HAI measures (that is, CLABSI, CAUTI, and SSI). To receive the exception, eligible hospitals must submit an IPPS Measure Exception Form annually.
| File Name | File Type | File Size | |
|---|---|---|---|
| FY 2026 IPPS Measure Exception Form | 215 KB | Download |
CMS PSI 90
For more information on the CMS PSI 90 measure, visit the QualityNet CMS PSI Resources page.
Submit questions about the CMS PSI 90 measure methodology via the QualityNet Question and Answer Tool.
CDC's NHSN HAI measures
For more information on the CDC's NHSN HAI measures, visit the following resources:
Submit questions about the CDC's NHSN HAI measure methodology directly to the NHSN at nhsn@cdc.gov.