Full Year 2015

Percentage of patients 18 years of age or older without carotid territory neurologic or retinal symptoms within 120 days immediately proceeding carotid angioplasty and stent (CAS) placement who experience stroke or death during their hospitalization for this procedure. This measure is proposed for both hospitals and individual interventionalists. This measure is currently reported by the Vascular Quality Initiative (VQI) Registry.

Percentage of patients age 18 or older without carotid territory neurologic or retinal symptoms within the one year immediately preceding carotid endarterectomy (CEA) who experience stroke or death following surgery while in the hospital. This measure is proposed for both hospitals and individual surgeons. This measure is presently reported by the Vascular Quality Initiative (VQI) registry.

Percentage of laboratory potassium samples drawn in the emergency department (ED) with hemolysis.

The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care:
Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
Rate 2: Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

The total number of patients that have hospital-acquired (nosocomial) category/stage II or greater pressure ulcers on the day of the prevalence measurement episode.

Pressure Ulcer Risk Assessment Conducted: Percentage of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start/resumption of care.

Pressure Ulcer Prevention Included in Plan of Care: Percentage of home health episodes of care in which the physician-ordered plan of care included interventions to prevent pressure ulcers.

Proportion of infants born from 22 weeks, 0 days to 29 weeks, 6 days gestational age who were in the reporting hospital at the postnatal age recommended for screening for retinopathy of prematurity (ROP) by the American Academy of Pediatrics (AAP) and who received a retinal examination for ROP prior to discharge.

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types:

Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period (Please reference attached document labeled NQF_Stroke_PACs_Risk_Adjustment_2.16.10.xls, tabs labeled CIP_Index PAC_Stays and CIP_PAC_Readmission). We define PACs during each time period as one of three types:

(A) PACs during the Index Stay (Hospitalization):

Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life