Patient Safety
Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Group Level)
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This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.
CBE ID3662e
Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)
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This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.
CBE ID3633e
Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility Level)
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This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.
CBE ID3663e
Exposure time reported for procedures using fluoroscopy
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Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time
CBE ID0510
Failure to Rescue 30-Day Mortality (risk adjusted)
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Percentage of patients who died with documented or undocumented complications within 30 days from admission
CBE ID0353
Failure to Rescue In-Hospital Mortality (risk adjusted)
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Percentage of patients who died with documented or undocumented complications in the hospital
CBE ID0352
Fall 2022 Post-Comment Meeting
Following the conclusion of the Fall 2022 public comment period, the project committee reviews submitted comments. After its review, the committee may choose to revise its recommendations within in response to a specific comment or series of comments. In addition the project committee will re-vote on measures in which consensus was not reached during the Fall 2022 measure evaluaiton meeting. Any revisions will be reflected in the final report.
Falls with injury
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All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.
(Total number of injury falls / Patient days) X 1000
Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.CBE ID0202
Gastrointestinal Hemorrhage Mortality Rate (IQI #18)
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In-hospital deaths per 1,000 hospital discharges with gastrointestinal hemorrhage as a principal diagnosis for patients age 18 years and older. Excludes obstetric discharges and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]CBE ID2065