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The standardized hospitalization ratio is defined to be the ratio of the number of hospital admissions that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of hospitalizations that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

Standardized mortality ratio is defined to be the ratio of the number of deaths that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of deaths that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

The Standardized Ratio of Emergency Department Encounters Occurring Within 30 Days of Hospital Discharge for Dialysis Facilities (ED30) is defined to be the ratio of observed over expected events. The numerator is the observed number of index discharges from acute care hospitals that are followed by an outpatient emergency department encounter within 4-30 days after discharge for eligible adult Medicare dialysis patients treated at a particular dialysis facility.

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

The percentage of patients ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication.

The percentage of patients aged 18 years and older who have been on chronic steroids for at least 180 days and had a bone density evaluation or were taking osteoporosis treatment

The STS Lobectomy Composite Score comprises two domains:

1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.

Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool

Documents the extent to which a provider uses a certified/qualified electronic health record (EHR) system capable of enhancing care management at the point of care. To qualify, the facility must have implemented processes within their EHR for disease management that incorporate the principles of care management at the point of care which include:
a. The ability to identify specific patients by diagnosis or medication use
b. The capacity to present alerts to the clinician for disease management, preventive services and wellness