Endorsed
Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network (NHSN), Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
Description
Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).
Cervical Cancer Screening
Description
The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
-Women 21–64 years of age who had cervical cytology performed within the last 3 years.
-Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
-Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years.
Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey
Description
The Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care.
The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:
Communication with Parent
1. Communication between you and your child’s nurses (3 items)
Childhood Immunization Status (CIS)
Description
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine.
Chlamydia Screening in Women (CHL)
Description
The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
Clinician-Group Risk-Standardized Acute Hospital Admission Rate for Patients with Multiple Chronic Conditions under the Merit-based Incentive Payment System
Description
Risk-Standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).
Clinician-Level and Clinician Group-Level Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA and TKA) Patient-Reported Outcome-Based Performance Measure (PRO-PM)
Description
This patient-reported outcome-based performance measure uses the same measure specifications as the NQF-endorsed (NQF # 3559) hospital-level risk-standardized improvement rate (RSIR) following elective primary THA/TKA with the following exception: this measure attributes the outcome to a clinician or clinician group. Specifically, this measure will estimate a clinician-level and/or a clinician group-level RSIR following elective primary THA/TKA for Medicare fee-for-service (FFS) patients 65 years of age and older.
CollaboRATE Shared Decision Making Score
Description
CollaboRATE is a patient-reported measure of shared decision making which contains three brief questions that patients, their parents, or their representatives complete following a clinical encounter. The CollaboRATE measure provides a performance score representing the percentage of adults 18 and older who experience a high level of shared decision making.
Composite measure for the quality of care provided to patients undergoing percutaneous coronary interventions (PCI).
Description
This is a weighted composite measure comprised of six component measures: three all-cause risk standardized outcome measures on all-cause mortality, bleeding, acute kidney injury and three process measures focused on discharge on guideline directed medical therapy, referral to a cardiac rehabilitation program and PCI performed within ninety minutes of symptoms for patients with acute myocardial infarctions. The target population includes adults (age 18 and greater) undergoing percutaneous coronary interventions. The timeframe for reporting will be a rolling four quarters.