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Patient Safety

Nursing Hours per Patient Day

  • 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.

    CBE ID
    0205

PACE Participant Fall Rate

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

    CBE ID
    3001

PACE-Acquired Pressure Ulcer/Injury Prevalence Rate

  • 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.

    CBE ID
    3000

Participation in a Systematic National Dose Index Registry

  • 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.

    CBE ID
    0740

Patient Fall

  • Percentage of ASC admissions experiencing a fall in the ASC.

    CBE ID
    0266

Patient Fall Rate

  • 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.

    CBE ID
    0141

Patient Safety

The Patient Safety Standing Committee  oversees the consensus based entity's portfolio of Patient Safety measures, including measures for the improper diagnosis of illness, appropriate radiation dosing, falls, pressure ulcers, etc.