Endorsed

Percentage of women who 1) received or had documented use of most or moderately effective contraception and 2) received a long-acting reversible contraceptive method during the calendar year. 

To focus the measure  on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated during the year that they did not want these services, as well as those who are eligible for postpartum contraceptive services during the measurement period.

Percentage of women 1) who received or had documented use of most or moderately effective contraception during the postpartum period (primary measure) and 2) received a long-acting reversible contraceptive method during the postpartum period (sub-measure). To focus the measure on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated they did not want these services. 

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.

SNF HAI is a one-year outcome measure that estimates the risk-standardized rate of healthcare-associated infections (HAIs) that are acquired during SNF care and result in hospitalization.

The Standardized Emergency Department Encounter Ratio is defined to be the ratio of the observed number of emergency department (ED) encounters that occur for adult Medicare ESRD dialysis patients treated at a particular facility to the number of encounters that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. Note that in this document an “emergency department encounter” always refers to an outpatient encounter that does not end in a hospital admission.

The standardized hospitalization ratio is defined to be the ratio of the number of hospital admissions that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of hospitalizations that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

Standardized mortality ratio is defined to be the ratio of the number of deaths that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of deaths that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

The Standardized Ratio of Emergency Department Encounters Occurring Within 30 Days of Hospital Discharge for Dialysis Facilities (ED30) is defined to be the ratio of observed over expected events. The numerator is the observed number of index discharges from acute care hospitals that are followed by an outpatient emergency department encounter within 4-30 days after discharge for eligible adult Medicare dialysis patients treated at a particular dialysis facility.

The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.

Percentage of patients aged 18 years and older undergoing infrainguinal lower extremity bypass who are prescribed a statin medication at discharge. This measure is proposed for both hospitals and individual providers.