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Spring 2019

Minimum Delivered Peritoneal Dialysis Dose

  • Percentage of patient months for adult and pediatric patients whose delivered peritoneal dialysis dose was a weekly Kt/Vurea (dialytic + residual) >= 1.7 (adult, >=18) or >= 1.8 (pediatric, <18).

    CBE ID
    2704

Nursing Hours per Patient Day

  • NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    Measure focus is structure of care quality in acute care hospital units.

    CBE ID
    0205

One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

  • Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received one-time screening for hepatitis C virus (HCV) infection

    CBE ID
    3059e

Operative Mortality Stratified by the 5 STAT Mortality Categories

  • Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Categories, a multi-institutional validated risk stratification tool

    CBE ID
    0733

Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

  • This measure reports the percentage of long-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.

    CBE ID
    0677

Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay)

  • This measure reports the percentage of short-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. Short-stay nursing facility residents are identified as those who have had 100 or fewer cumulative days of nursing facility care.

    CBE ID
    0676

Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections

  • Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

    CBE ID
    2726

Proportion of Days Covered (PDC): 3 Rates by Therapeutic Category

  • The percentage of individuals 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80 percent during the measurement year.

    Report a rate for each of the following:
    • Diabetes All Class (PDC-DR)
    • Renin Angiotensin System Antagonists (PDC-RASA)
    • Statins (PDC-STA)

    A higher rate indicates better performance.

    CBE ID
    0541

Rheumatoid Arthritis: Assessment of Disease Activity

  • Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

    CBE ID
    2523