Patient Safety

The inappropriate diagnosis of UTI in hospitalized medical patients (or “Inappropriate Diagnosis of UTI”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for UTI who do not meet diagnostic criteria for UTI (thus are inappropriately diagnosed and overtreated).

Percentage of episodes with an International Normalized Ratio (INR) test performed three to seven days after a newly started interacting anti-infective medication for individuals receiving warfarin

Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic International Normalized Ratio (INR) who had an INR test within 14 days of hospital discharge

This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

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

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.

The quarterly incidence rate of falls amongst PACE participants per 1,000 participant days.

The quarterly incidence rate of falls with injury amongst PACE participants per 1,000 participant days.

Prevalence of PACE-acquired pressure ulcers/injuries (Stages 3, 4, unstageable, and deep tissue injury) among PACE participants in a quarter, expressed as persons with 1 or more pressure ulcers/injuries divided by the number of participants on the PACE organization’s census who resided in a home setting (home or assisted living facility)for at least one day during the quarter.

Participation in a multi-center, standardized data collection and feedback program that will establish national dose index benchmarks for designated examinations. The registry will eventually provide a comparison of practice or facility dose indices such as CTDIvol and DLP for specified examinations relative to national and regional benchmarks. Data is captured electronically from the images of CT examinations using Digital Imaging and Communications in Medicine (DICOM) standards and the Integrating the Healthcare Enterprise (IHE) Radiation Exposure Monitoring (REM) profile.