Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits
A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.
In-hospital deaths per 1,000 hospital discharges with gastrointestinal hemorrhage as a principal diagnosis for patients age 18 years and older. Excludes obstetric discharges and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]
The following 6 composites and 1 single-item measure are generated from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surgical Care Survey. Each measure is used to assess a particular domain of surgical care quality from the patient’s perspective.
Measure 1: Information to help you prepare for surgery (2 items)
Measure 2: How well surgeon communicates with patients before surgery (4 items)
Measure 3: Surgeon’s attentiveness on day of surgery (2 items)
Measure 4: Information to help you recover from surgery (4 items)
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
Percentage of SUI surgeries for which cystoscopy was used during the surgical procedure to reduce complications
This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.
Percentage of intensive care unit patients on mechanical ventilation
at time of survey for whom all five elements of the ventilator bundle are documented and in place. The ventilator bundle elements are:
•Head of bed (HOB) elevation 30 degrees or greater (unless medically contraindicated)
•Daily “”sedation interruption” and daily assessment of readiness to extubate •Peptic ulcer disease prophylaxis
•Deep Venous Thrombosis prophylaxis
•Daily oral care with Chlorhexidine
Percentage of intensive care patients with central lines for whom all
elements of the central line bundle are documented and in place.
The central line bundle elements include:
•Hand hygiene
•Maximal barrier precautions upon insertion
•Chlorhexidine skin antisepsis
•Optimal catheter site selection, with avoidance of the femoral vein for central venous access in patients 18 years and older
•Daily review of line necessity with prompt removal of unnecessary lines
Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.
Percentage of adult (age 18 and older) U.S. population that currently smoke.