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Valid for Measure Submission

Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract)

  • NSC-12.1 - Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit.

    NSC-12.2 - Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit.

    NSC-12.3 - Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit.

    CBE ID
    0204

Surgical Volume for Pediatric and Congenital Heart Surgery: Total Programmatic Volume and Programmatic Volume Stratified by the 5 STAT Mortality Categories

  • Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool

    CBE ID
    0732

The Ability to use Health Information Technology to Perform Care Management at the Point of Care

  • Documents the extent to which a provider uses a certified/qualified electronic health record (EHR) system capable of enhancing care management at the point of care. To qualify, the facility must have implemented processes within their EHR for disease management that incorporate the principles of care management at the point of care which include:
    a. The ability to identify specific patients by diagnosis or medication use
    b. The capacity to present alerts to the clinician for disease management, preventive services and wellness

    CBE ID
    0490

Tracking of Clinical Results Between Visits

  • Documentation of the extent to which a provider uses a certified/qualified electronic health record (EHR) system to track pending laboratory tests, diagnostic studies (including common preventive screenings) or patient referrals. The Electronic Health Record includes provider reminders when clinical results are not received within a predefined timeframe.

    CBE ID
    0491

Voluntary Turnover

  • NSC-11.1 Total number of full-time and part-time Registered Nurse (RN) and Advanced Practice Nurse (APN) voluntary uncontrolled separations occurring during the calendar month
    NSC-11.2 Total number of full-time and part-time Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) voluntary uncontrolled separations occurring during the calendar month
    NSC-11.3 Total number of full-time and part-time Unlicensed Assistive Personnel (UAP) voluntary uncontrolled separations occurring during the calendar month

    CBE ID
    0207