Fall 2024

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

The Bereaved Family Survey-Performance Measure (BFS-PM) is an outcome measure that is used to assess overall quality of care in the last month of life.  Currently, the BFS is administered to the next-of-kin of all Veterans who die in a VA inpatient setting (i.e., acute units, intensive care units, inpatient hospice and palliative care units, and VA nursing homes) 4-6 weeks post-death. The BFS-PM is calculated using the global rating item included on the 20-item BFS that has separate versions for male and female Veterans and is available in English and Spanish.

This is a weighted composite measure comprised of six component measures: three all-cause risk standardized outcome measures on all-cause mortality, bleeding, acute kidney injury and three process measures focused on discharge on guideline directed medical therapy, referral to a cardiac rehabilitation program and PCI performed within ninety minutes of symptoms for patients with acute myocardial infarctions. The target population includes adults (age 18 and greater) undergoing percutaneous coronary interventions. The timeframe for reporting will be a rolling four quarters.  

The measure calculates the percentage of family or designated responsible party for assisted living (AL) residents. This consumer reported outcome measure is based on the CoreQ: AL Family Satisfaction questionnaire that has three items.

The measure calculates the percentage of Assisted living (AL) residents, those living in the facility for two weeks or more, who are satisfied. This patient reported outcome measure is based on the CoreQ: AL Resident Satisfaction questionnaire that is a four-item questionnaire.

This outcome measure estimates the percentage of Inpatient Rehabilitation Facility (IRF) Medicare patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics. The measure includes patients who are 18 years of age or older and the timeframe for the measure is 12 months.

This outcome measure estimates the percentage of Long-Term Care Hospital (LTCH) patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients 18 years of age or older and the measure timeframe is 12 months.

This outcome measure estimates the percentage of Medicare Part A skilled nursing facility stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients who are 18 years of age or older and the measure timeframe is 12 months.

This outcome measure estimates the percentage of Home Health (HH) Medicare patients (18+) who meet or exceed an expected discharge function score over a 12-month period.

The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics.

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.