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Full Year 2011

ESRD- HD Adequacy CPM III: Minimum Delivered Hemodialysis Dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 90 days or greater.

  • Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2 during the reporting period.

    CBE ID
    0250

Measurement of Serum Calcium Concentration

  • Percentage of all adult peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum calcium measured at least once within month

    CBE ID
    0261

Medical Home System Survey (MHSS)

  • The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

    Composite 1: Patient-Centered Access
    Composite 2: Team-Based Care
    Composite 3: Population Health Management
    Composite 4: Care Management and Support
    Composite 5: Care Coordination and Care Transitions

    CBE ID
    1909

Medication Reconciliation Post-Discharge (MRP)

  • The percentage of discharges during the first 11 months of the measurement year (e.g., January 1–December 1) for patients 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.

    CBE ID
    0554

National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure

  • De.2. Brief description of measure
    Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (CAUTI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs) (excluding patients in neonatal ICUs [NICUs: Level II/III and Level III nurseries])
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0752

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs)
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0754

Patient Education Awareness—Facility Level

  • Percentage of a physician´s end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

    CBE ID
    0324