Outcome

This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.

This facility-level measure estimates an all-cause, unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease.

The performance period for the measure is 24 months.

Percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first “operating room” procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication. 

The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 17 years and younger. Excludes cases with a principal diagnosis of transfusion reaction, cases with a secondary diagnosis of transfusion reaction that is present on admission, neonates, and obstetric cases.

The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 18 years and older or obstetric patients. Excludes cases with a principal diagnosis of transfusion reaction or cases with a secondary diagnosis of transfusion reaction that is present on admission.

Admissions for a principal diagnosis of diabetes without mention of short-term (ketoacidosis, hyperosmolarity, or coma) or long-term (renal, eye, neurological, circulatory, or other unspecified) complications per 100,000 population, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

The number per 1,000 livebirths of <1500g infants delivered at hospitals not appropriate for that size infant.

This is a hospital level performance score reported as the percent of infants with Unexpected Newborn Complications among full term newborns with no preexisting conditions, typically calculated per year.

Accidental punctures or lacerations (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older who have undergone an abdominopelvic procedure; in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. Excludes cases with accidental puncture or laceration as a principal diagnosis, cases with accidental puncture or laceration as a secondary diagnosis that is present on admission, and obstetric cases.

Admissions with a principal diagnosis of urinary tract infection per 100,000 population, ages 18 years and older. Excludes kidney or urinary tract disorder admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]