Fall 2020

NQF #0496 calculates the median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department (ED). The measure is calculated using chart-abstracted data, on a rolling quarterly basis, and is publically reported in aggregate for one calendar year. The measure has been publically reported since 2013 as part of the ED Throughput measure set of the CMS’ Hospital Outpatient Quality Reporting (HOQR) Program.

The MSPB Hospital measure evaluates hospitals’ risk-adjusted episode costs relative to the risk-adjusted episode costs of the national median hospital. Specifically, the MSPB Hospital measure assesses the cost to Medicare for Part A and Part B services performed by hospitals and other healthcare providers during an MSPB Hospital episode, which is comprised of the periods 3-days prior to, during, and 30-days following a patient’s hospital stay. The MSPB Hospital measure is not condition specific and uses standardized prices when measuring costs.

This measure assesses whether patients discharged from an inpatient psychiatric facility (IPF) with major depressive disorder (MDD), schizophrenia, or bipolar disorder filled a prescription for evidence-based medication within 2 days prior to discharge and 30 days post-discharge. This measure evaluates admissions over a two-year period.

A composite measure of in-hospital mortality indicators for selected conditions.

Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.
(Total number of falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

PSI 90 is a composite of ten adverse event indicators that summarizes hospitals’ performance on patient safety for the CMS Medicare fee-for-service population. The timeframe used in the CMS Hospital Acquired Conditions Reduction Program (HACRP) and CareCompare public reporting are set within the Inpatient Prospective Payment Systems (IPPS) Final Rule annually. Typically, the performance periods use multiple months of claims data.

This measure assesses patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids prior to delivering preterm newborns. This measure is a part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding; Beginning 1/1/2019 PC-06 Unexpected Complications in Term Newborns will be added).

This measure estimates the rate of emergency department visits for children ages 3 – 21 who are being managed for identifiable asthma, using specified definitions. The measure is reported in visits per 100 child-years.