Deconstructing the Hospital Harm - Postoperative Respiratory Failure eCQM

There’s a lot of excitement brewing here at Medisolv over the latest hospital harm eCQM, Postoperative Respiratory Failure (HH-RF or CMS1218), which was finalized in the 2025 IPPS Final Rule. Along with the Hospital Harm - Falls with Injury eCQM, this brings the total number of Hospital Harm measures to seven. If you are thinking this measure sounds familiar, you're right. HH-RF is the eCQM equivalent of PSI 11 (Postoperative Respiratory Failure Rate). Safety is a major focus for CMS as well as a digital push. Many of these new Hospital Harm eCQM have matching PSIs, so it's important to get ahead of these measures as CMS rolls them out. And we're here to assist you every step of the way! 

HH-RF is a voluntary measure in 2026 and will be evaluated for TEAM model hospitals in 2027. 

Why is this Measure Important? 

HH-RF's goal is to improve the quality of care in hospitals by reducing the number of patients who have postoperative respiratory failure (PRF) after elective surgeries. This will lead to better patient safety.

HH-RF is designed to monitor the incidence of postoperative respiratory failure (PRF), a potentially life-threatening complication that can occur after surgical procedures.  By encouraging hospitals to monitor and analyze their PRF rates, this measure will promote the adoption of evidence-based practices and protocols to decrease the chances of postoperative respiratory failure.

The importance of reducing the risk of PRF is clear to many of you, but for those who may be new to this topic, here’s some additional context. This complication can have a significant impact on patient outcomes and is characterized by events such as unplanned endotracheal reintubation or extended use of mechanical ventilation. PRF can result in higher rates of mortality and morbidity, with in-hospital death rates reaching up to 40% making it the most common serious postoperative pulmonary complication. 

Patients who experience PRF are at a much higher risk of death, readmission, or the need for additional medical care, including rehabilitation or skilled nursing facility placement. The variation in PRF rates among different hospitals, with higher incidences often seen in larger facilities and non-teaching hospitals, underscores the necessity for a standardized measure to monitor PRF and provide data to support efforts to enhance care.

Navigating the Complexity of HH-RF 

eCQMs can be complex and challenging to understand, even those that seem straightforward. While the intent of an eCQM is typically clear and supported by healthcare professionals, the logic, value sets, codes, and other requirements can often obscure the measure's importance. With that, I’ll give you a warning, the HH-RF specification and requirements contain an overwhelming blend of complex logic, data elements that have not been used in previous eCQMs, and many new codes. If you want to play a game of “stump the eCQM expert” this might be the winning measure.

I suggest you approach this as a marathon rather than a sprint. Starting early will give you time to fix any problems so that when the first performance period starts, you are ready to use the measure's results to reduce the incidence of PRF at your hospital.  

Understanding the Specification 

The intent of HH-RF is to assess the number of elective inpatient hospitalizations for patients aged 18 and older (without an obstetric diagnosis), who have a procedure resulting in postoperative respiratory failure. It sounds simple enough, but the complexity arises when you delve into the populations that make up the measure. 

Initial Population 

Just to give you a peek into the specification logic, here’s just one section of the spec's initial population logic… 

Here's our simplified logic for you… 

For a patient encounter to qualify for the Initial Population and Denominator (the logic is the same for both), the patient must have an inpatient elective surgical encounter. They must be 18 years of age or older and have had at least one surgical procedure performed within the first 3 days of their hospital stay. The patient must not have had any emergency visits within 24 hours of their hospital admission and must not have any obstetrical or pregnancy-related conditions. 

Initial Population/Denominator

• Elective Inpatient encounter (includes inpatient admissions from outpatient surgery - new encounter type that needs to be mapped like IN/OBS/ED)
• Encounter class elective qualifier value
• Without an ED visit
• >18 years of age
• Surgical Anesthesia Procedure within 3 days of encounter start (uses first procedure if more than one)
• Without OB Condition

You can see why we like to translate this into a language that we can understand. There’s no way I could explain those brackets, quotations, and parentheses (that’s where Medisolv's amazing measure developers come in!). 

Exclusions 

Simplified Logic: 

Once the IP/Denominator population is determined, any patients with the following will be excluded and will not impact your performance rate. 

• Degenerative Neurological Disorder
  
  • Patients who have a degenerative neurological disorder
• High Risk to Airway Head Neck and Thoracic Surgery
  • Patients at high risk for airway, head, neck, or thoracic surgery
• Mechanical Ventilation that Starts More than One Hour Prior to Start of First OR Procedure
  • Patients who started mechanical ventilation more than one hour before their first operating room (OR) procedure
• Neuromuscular Disorder
  • Patients with a neuromuscular disorder
• PaCO2 Greater Than 50 and Arterial pH Less Than 7.30 within 48 hours Prior to Start of First OR Procedure
  • Patients with a PaCO2 level greater than 50 and an arterial pH less than 7.30 within 48 hours before the first OR procedure
• PaO2 Less than 50 within 48 hours Prior to Start of First OR Procedure
  • Patients with a PaO2 level less than 50 within the same 48-hour period 
• Principal Diagnosis of Acute Respiratory Failure with Rank of 1
  • Patients with a principal diagnosis of acute respiratory failure
• Secondary Diagnosis of Acute Respiratory Failure Present on Admission with Rank >2
  • Patients with a secondary diagnosis of acute respiratory failure present on admission
• Tracheostomy Present on Admission
• Tracheostomy Prior to or on the Same Day of First OR Procedure
  
  • Patients with a tracheostomy either present on admission or performed prior to or on the same day as the first OR procedure

Note: When you implement this measure, pay close attention to the timing requirements. Those are always tricky. Additionally, the exclusion statement ‘Rank > 2’ is new to eCQMs. We expect this to cause some bumps in the road. 

Numerator 

Now here’s where things get really complicated. The specification description (metadata summary) of the Numerator is any encounter, not excluded, that has: 

• Intubation outside the procedural area within 30 days after the end of the first OR procedure. 

Or 

• Mechanical ventilation (MV) outside the procedural area within 30 days after the end of the first OR procedure AND preceded by non-invasive oxygen therapy. 

Or 

• Extubation outside the procedural area within 30 days after the end of the first OR procedure, more than 48 hours after the end of anesthesia. 

Or 

• MV within 30 days after the end of the first OR procedure; between 48 and 72 hours after the end of the OR procedure and not preceded by non-invasive oxygen therapy or anesthesia. 

But when you take a closer look at the logic, data elements, and other requirements, things are much (much!) more complicated. Each of the four Numerator qualifying statements above have additional details that must be considered to understand and implement the measure correctly. The more accurate depiction of the numerator measure logic is below: 

Note: Yup, there are a LOT of timing requirements again, and new data elements that are making their eCQM debut, such as intubation, oxygen therapy, and procedural areas. Operating Room is a part of other eCQMs but HH-RF is evaluating more than just the OR, you’ll need to map other procedure areas as well. 

It’s exhausting, huh?! Unfortunately, we aren’t done yet. This measure also includes risk variables that must be evaluated and included in the QRDA file when you submit. Risk variables don’t impact your eCQM populations or results but are used by CMS to risk-adjust your results AFTER submission. Including these variables is important as CMS will adjust your overall rates for HH-RF based on how sick your patients were. You’ll receive your risk-adjusted results when your Hospital Specific Reports (HSRs) are made available. 

Below is a list of all risk variables and the associated unit of measure (if applicable). You need to make sure that each of these elements (and there are a lot) are captured electronically in structured fields and that each is mapped correctly, just like you would for any eCQM data element.

First resulted vital sign values: 

• Body temperature Cel, [degF]  

• Heart rate {Beats}/min 

• Respiratory rate {Breaths}/min 

• Systolic blood pressure: mm[Hg] 

First resulted laboratory test values: 

• Albumin g/dL, umol/L 

• Aspartate aminotransferase (AST/SGOT) U/L, IU/L 

• Bicarbonate mmol/L 

• Bilirubin mg/dL, umol/L 

• Blood urea nitrogen (BUN) mg/dL, umol/L 

• Carbon dioxide (partial pressure) mm[Hg] 

• Creatinine mg/dL, umol/L 

• Hematocrit % 

• Hemoglobin g/dL, mmol/L 

• Leukocyte count {cells}/uL, 10*3/uL, 10*9/L, /mm3 

• Oxygen (partial pressure) mm[Hg] 

• pH of arterial blood [pH] 

• Platelet count 10*3/uL, 10*9/L, /mm3 

• Sodium meq/L, mmol/L 

• White blood cell count {cells}/uL, 10*3/uL, 10*9/L, /mm3  

Additional variables used for risk adjustment:  

• American Society of Anesthesiologists (ASA) physical status class assessment 

• First Body mass index (BMI), reported using UCUM unit: kg/m2 

• All encounter diagnoses with their Present on Admission (POA) indicators + Rank 

• All encounter procedures + Rank 
• Most recent smoking status 

Note: Just like Hybrid measures, units are important here. Make sure you include the correct units in association with the results above when you submit your QRDA file. Also, the risk variables require submission of all encounter diagnoses and procedures! That could result in a lot of data in those files. CMS says they’re ready to accept significantly larger QRDA files, but we’ll be doing some testing to confirm that — historically, larger-than-expected files have been rejected upon submission. Just another reason to get started on this measure early. 

Helpful Tips 

Here are the helpful tips for getting started with implementing this eCQM: 

1. Review the specifications thoroughly to ensure you understand the measure requirements. 
2. Determine who needs to be involved in the implementation process and establish a team. 
3. Ensure you have a clear understanding of the procedural locations and how they are mapped in your system. 
4. Start working on implementing the measure as soon as possible to ensure a smooth transition. 
5. Remember to consult the eCQI Resource Center for additional resources and guidance on implementing eCQMs.