Percentage of patients aged 18 years and older at the start of the measurement period with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.
Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CAUTIs by the number of predicted CAUTIs.
Number of annually observed catheter-associated urinary tract infections (CAUTI) in hospital inpatients.
N/A
N/A
Number of annually predicted catheter-associated urinary tract infections (CAUTI) in hospital inpatients.
The following are not considered indwelling catheters by NHSN definitions:
N/A
Endorsement History:
Link to Endorsement Measure Record: National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
Impact Summary: This measure supports the Long-Term Care Hospital Quality Reporting Program by assessing health care-associated catheter-associated urinary tract infections (CAUTI) among patients in bedded long-term care hospitals, an outcome directly associated with patient safety and quality of care.
There was no discernible change in performance among entities reporting on this measure during the years examined. Based on the most recent data, the total estimated number of CAUTIs across all deciles is approximately 1,400. If long-term care hospitals with higher CAUTI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that up to about 1,000 CAUTIs could potentially be avoided, representing a meaningful opportunity for improved patient outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_006_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: There is no discernible change across the 4 years; the median score had a range between a minimum of 0.57 to a maximum of 0.61. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores (standardized infection ratios [SIRs]), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.
For this measure, Decile 1 represents a group of 32 hospitals with the highest measure scores and Decile 10 shows those with the lowest measure scores.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average SIR (Standard Deviation) | 0.760 (0.730) | 0 | 0 | 0.233 | 0.425 | 0.515 | 0.651 | 0.902 | 1.19 | 1.409 | 2.217 |
| Average Raw Rate (Standard Deviation) | 0.130 (0.122) | 0 | 0 | 0.037 | 0.067 | 0.089 | 0.111 | 0.147 | 0.192 | 0.241 | 0.394 |
| Entities | 312 | 32 | 31 | 31 | 31 | 31 | 32 | 31 | 31 | 31 | 31 |
| Patients | 1,058,542 | 76,535 | 74,451 | 125,653 | 106,053 | 125,180 | 115,518 | 110,660 | 101,551 | 107,002 | 115,939 |
Table 1 Interpretation: To estimate the number of negative outcomes (CAUTIs), the number of patients is multiplied by the average raw rate for each decile. In 2024, the total estimated number of negative outcomes across all deciles is about 1,400. If the average performance of Decile 3 (0.037%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 1,000 fewer negative outcomes could occur. This translates to about three patients per entity and means that improving performance on this measure could help ensure that several hundred fewer patients contract CAUTIs, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Annual risk-adjusted standardized infection ratio (SIR) of central line-associated bloodstream infections (CLABSI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, and long-term acute care hospitals. SIR is reported annually and is calculated by dividing the number of observed CLABSIs by the number of predicted CLABSIs.
Number of annually observed central line-associated bloodstream infections (CLABSI) in hospital inpatients.
N/A
N/A
Number of annually predicted central-line associated bloodstream infections (CLABSI) in hospital inpatients.
The following devices are not considered central lines and are excluded:
CLABSI events reported to NHSN as mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBIs) are excluded.
N/A
Endorsement History:
Link to Endorsement Measure Record: Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio | Partnership for Quality Measurement
Impact Summary: This measure supports the Long-Term Care Hospital Quality Reporting Program by assessing health care–associated central line–associated bloodstream infections (CLABSIs) among patients in long-term care hospitals, an outcome closely associated with patient safety and infection prevention.
Based on the most recent data, the total estimated number of CLABSIs across all deciles is approximately 1,200. If long-term care hospitals with higher CLABSI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that up to about 1,000 CLABSIs could potentially be avoided, indicating a substantial opportunity for improved patient outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_007_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: There is little discernible change across the 4 years; the median score ranged between a minimum of 0.51 to a maximum of 0.59. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores (standardized infection ratio [SIR]), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.
Table 1. Importance (Decile by Measure Score, FY2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average SIR (Standard Deviation) | 0.750 (0.815) | 0 | 0 | 0.121 | 0.308 | 0.531 | 0.661 | 0.854 | 1.037 | 1.500 | 2.500 |
| Average Raw Rate (Standard Deviation) | 0.090 (0.137) | 0 | 0 | 0.011 | 0.036 | 0.054 | 0.074 | 0.099 | 0.124 | 0.176 | 0.361 |
| Entities | 312 | 32 | 31 | 31 | 31 | 31 | 32 | 31 | 31 | 31 | 31 |
| Patients | 1,230,531 | 100,154 | 69,485 | 131,684 | 142,337 | 125,319 | 153,281 | 129,301 | 150,564 | 109,106 | 119,300 |
Table 1 Interpretation: To estimate the number of negative outcomes (CLABSIs), the number of patients is multiplied by the average raw rate for each decile. In 2024, the total estimated number of negative outcomes across all deciles is about 1,200. If the average performance of Decile 3 (0.011%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 1,000 fewer negative outcomes could occur. This translates to about three patients per entity and means that improving performance on this measure could help ensure that several hundred fewer patients contract CLABSIs, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs.
Number of annually observed Clostridioides difficile (CDI) LabID events in hospital inpatients.
N/A
N/A
Number of annually predicted Clostridioides difficile (CDI) LabID events in hospital inpatients.
Baby based locations such as neonatal ICU, special care nursery and well-baby nurseries, are excluded from the denominator count. In LDRP locations, moms and babies must each be counted separately (as two patients). Any locations that predominantly house infants, including NICU, SCN, or well-baby locations (for example, nurseries, babies in LDRP) are excluded.
N/A
Endorsement History: The measure was last endorsed in 2025 and is up for re-endorsement in 2029
Link to Endorsement Measure Record: Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio | Partnership for Quality Measurement
Impact Summary: This measure supports the Long-Term Care Hospital Quality Reporting Program by assessing facility-wide hospital-onset Clostridioides difficile infections (CDIs) among patients in long-term care hospitals, an outcome closely associated with patient safety and infection prevention.
Based on the most recent data, the total estimated number of CDIs across all deciles is approximately 1,000. If long-term care hospitals with higher CDI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that several hundred CDIs could potentially be avoided, indicating a meaningful opportunity for improved patient outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_014_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Although there was no discernible change from 2021 to 2022, Figure 1 shows a decreasing trend from a median standardized infection ratio (SIR) of 0.3 in 2022 to a median SIR of 0.2 in 2024. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores (SIRs), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller group size may be associated with lower performance scores.
Table 1. Importance (Decile by Measure Score, FY2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average SIR (Standard Deviation) | 0.300 (0.335) | 0 | 0 | 0.036 | 0.110 | 0.173 | 0.241 | 0.317 | 0.461 | 0.655 | 1.049 |
| Average Raw Rate (Standard Deviation) | 0.030 (0.030) | 0 | 0 | 0.003 | 0.011 | 0.016 | 0.021 | 0.029 | 0.042 | 0.059 | 0.095 |
| Entities | 312 | 32 | 31 | 31 | 31 | 31 | 32 | 31 | 31 | 31 | 31 |
| Patients | 4,207,696 | 304,536 | 206,866 | 852,566 | 449,200 | 482,814 | 466,775 | 363,369 | 434,037 | 325,420 | 322,113 |
Table 1 Interpretation: To estimate the number of negative outcomes (CDIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,000. If the average performance of Decile 3 (0.003%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 900 fewer negative outcomes could occur. This translates to about three patients per entity and means that improving performance on this measure could help ensure that several hundred fewer patients contract CDIs, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This measure assesses facility-level compliance with Spontaneous Breathing Trial (SBT), including Tracheostomy Collar Trial (TCT) or Continuous Positive Airway Pressure (CPAP) breathing trial, by Day 2 of the Long-Term Care Hospital (LTCH) stay for patients on invasive mechanical ventilation support upon admission, and for whom at admission weaning attempts were expected or anticipated at admission. This measure will be computed and reported separately according to each of the following components:
Component 1: LTCH stays in which patients are admitted on invasive mechanical ventilation for whom the LTCH Admission assessment (A0250 = [01]) indicates:
Component 2: LTCH stays in which patients are admitted on invasive mechanical ventilation for whom the LTCH Admission assessment (A0250 = [01]) indicates SBT performed by day 2 of the LTCH stay (O0150E = [1](yes)).
N/A
N/A
Component 1: LTCH stays in which patients who were on invasive mechanical ventilation support upon admission to an LTCH, for whom weaning attempts are expected or anticipated (for LTCH stays with admission date from 07/01/2018 through 09/30/2022: O0150A = [1] (yes, on weaning); for LTCH stays with admission date on and after 10/01/2022: O0150A = [1] (yes, on ventilation) and O0150A2 = [1] (yes, weaning)).
Component 2: The subset of LTCH stays in which patients in the numerator of Component 1 were assessed and deemed ready for SBT by Day 2 of the LTCH stay (O0150B = [1] (yes) and O0150C = [1] (yes)).
LTCH stay is excluded from both Component 1 and Component 2 if:
1. LTCH stay is missing data to calculate the measure (for LTCH stays with admission date from 07/01/2018 through 09/30/2022: O0150A = [-]; for stays with admission date on and after 10/01/2022: O0150A = [-] or O0150A2 = [-]), OR
2. LTCH stays in which weaning attempts are not expected or anticipated at admission for the patient (for LTCH stays with admission date from 07/01/2018 through 09/30/2022: O0150A = [0] (No, not invasive mechanical ventilation support), or O0150A = [2] (Yes, non-weaning); for LTCH stays with admission date on and after 10/01/2022: O0150A = [0] (No, not invasive mechanical ventilation support), or O0150A = [1] and O150A2 = [0] (Yes, non-weaning)).
N/A
N/A
Impact Summary: This measure supports the Long‑Term Care Hospital (LTCH) Quality Reporting Program goal of measuring and improving the quality of care provided in long‑term care hospitals by assessing LTCH compliance with timely spontaneous breathing trials for patients on mechanical ventilation, a key clinical practice that informs ventilator management, supports care coordination, and improves outcomes for medically complex patients with prolonged hospital stays.
Hospital performance has stayed steady for Component 1 from 2023 to 2024 and increased slightly for Component 2 from 2023 to 2024. For Component 1, the measure identified 23,000 eligible patients assessed for readiness for SBT. Improving performance among lower-scoring hospitals could help ensure about 1,100 patients are assessed for readiness, or about four per entity, potentially leading to better health outcomes. For Component 2, the measure identified 19,100 eligible patients assessed for readiness for SBT. Improving performance among lower-scoring hospitals may help less than two patients per entity; therefore, a benefit may not exceed the entity-level burden of quality data collection.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_022_02” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file. We analyzed rates for Component 1 and Component 2 separately.
About Figure 1: Figures 1a and 1b are boxplots that show how scores have changed based on the most recent 2 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1a. Boxplot of Measure Performance Rate by Year (Component 1)
Figure 1b. Boxplot of Measure Performance Rate by Year (Component 2)
Figure 1a and 1b Interpretation: Figure 1a shows little discernible change between 2023 and 2024. Although the median value for Component 2 is 100% for both years, in Figure 1b the mean value increases slightly from 95.6% in 2023 to 97.8% in 2024. The mean in 2023 was lower because about 5% of the entities had a score of less than 60% whereas only one entity had a performance rate less than 60% in 2024. For these measures, a higher performance rate indicates better quality of care.
About Table 1: Tables 1a and 1b illustrate the distribution of performance rates and the population represented within each group for each component. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest rates may contain smaller or larger populations than other groups. For example, if the lowest-scoring decile includes only 5% of the total population, then smaller group size may be associated with lower performance rates.
Table 1a. Importance (Decile by Measure Performance Rate, 2024) in the Most Recent Year of Data Available – Component 1
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 95.6 (11.3) | 72.5 | 92.7 | 95.8 | 97.4 | 98.4 | 99.4 | 100 | 100 | 100 | 100 |
| Entities | 264 | 27 | 26 | 27 | 26 | 26 | 27 | 26 | 27 | 26 | 26 |
| Patients | 24,059 | 2,416 | 2,354 | 2,523 | 2,183 | 3,003 | 4,291 | 1,820 | 1,815 | 1,924 | 1,730 |
Table 1b. Importance (Decile by Measure Performance Rate, 2024) in the Most Recent Year of Data Available – Component 2
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 97.8 (5.6) | 84.9 | 96.1 | 97.9 | 99.4 | 100 | 100 | 100 | 100 | 100 | 100 |
| Entities | 246 | 25 | 25 | 24 | 25 | 24 | 25 | 25 | 24 | 25 | 24 |
| Patients | 19,540 | 2,018 | 1,815 | 1,821 | 3,008 | 1,565 | 1,940 | 2,395 | 1,758 | 1,650 | 1,570 |
Table 1a and 1b Interpretation: To estimate the number of positive outcomes, the number of patients is multiplied by the average rate for each decile. In 2024, for Component 1, the total estimated number of positive outcomes (eligible patients assessed for readiness for SBT) across all deciles is about 23,000. If the average performance of decile 8 (100%) is considered a plausible, achievable score, and the entities in deciles 1 through 7 improved to reach that score, about 1,000 additional positive outcomes could occur. This translates to about four patients per entity and means that improving performance on this measure could help ensure that several hundred more patients are assessed for readiness, potentially leading to better health outcomes. For Component 2, the total estimated number of positive outcomes (eligible patients who received SBT) across all deciles is about 19,100. If the average performance of decile 8 (100%) is considered a plausible, achievable score, and the entities in deciles 1 through 7 improved to reach that rate, about 400 additional patients would receive SBT, which translates to less than two patients per entity.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
The numerator for this measure consists of HCP in the denominator population, who fall into one of the categories below. HCP should be counted as vaccinated if they receive influenza vaccine any time from when it first became available, such as August or September, through March 31 of the following year.
N/A
N/A
The denominator for this measure consists of healthcare personnel (HCP) who are physically present in the healthcare facility for at least 1 working day between October 1 through March 31 of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:
None
N/A
Link to Endorsement Measure Record: Influenza Vaccination Coverage Among Healthcare Personnel
Impact Summary: This measure supports the Long‑Term Care Hospital (LTCH) Quality Reporting Program goal of measuring and improving the quality of care provided in long‑term care hospitals by assessing whether LTCHs implement a core patient‑safety and infection‑prevention practice, health care personnel influenza vaccination, to support safer care environments and improve the quality of care for patients with complex, prolonged hospital stays.
Facility performance decreased between 2020 and 2021, then had little discernable change from 2021 to 2024, showing an opportunity for improvement in vaccination of HCP. Improving performance among lower-scoring facilities could help ensure 17,500 additional HCP, or about 58 HCP per entity, receive influenza vaccinations.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_015_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Figure 1 shows a drop from a median value of nearly 83% in 2020 to a median value of 70.3% in 2021. There has been little discernible change since 2021. For this measure, a higher score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the population represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain larger or smaller populations than other groups. For example, if the lowest-scoring decile includes only 5% of the total population, then smaller group size may be associated with lower performance scores.
Table 1. Importance in the most recent year of data available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 69.1 (19.5) | 30.3 | 49.0 | 56.6 | 63.0 | 68.5 | 73.4 | 79.2 | 84.6 | 90.7 | 96.5 |
| Entities | 304 | 31 | 30 | 31 | 30 | 30 | 31 | 30 | 31 | 30 | 30 |
| Population | 100,241 | 10,029 | 9,606 | 11,159 | 10,642 | 8,631 | 11,951 | 8,950 | 7,587 | 8,052 | 13,634 |
Table 1 Interpretation: To estimate the number of positive outcomes (influenza vaccinations for health care personnel), the population is multiplied by the average score for each decile. Right now, the total estimated number of positive outcomes across all deciles is about 70,000. If the average performance of Decile 8 (84.6%) is considered a plausible, achievable score, and the entities in Deciles 1 through 7 improved to reach that score, about 17,500 additional positive outcomes could occur. This translates to about 58 health care personnel per entity and means that improving performance on this measure could help ensure that several thousand more health care workers receive influenza vaccinations, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
This measure estimates the risk-adjusted change in mobility score between admission and discharge among LTCH patients requiring ventilator support at admission.
This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.
This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period.