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Hospital: Inpatient

Valid for Measure Submission

Hospital Harm – Falls with Injury

  • This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older.

    CBE ID
    4120e

Hospital Harm – Postoperative Respiratory Failure

  • This electronic clinical quality measure (eCQM) assesses the proportion of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF).

    CBE ID
    4130e

Hospital Risk-Standardized Complication Rate Following Implantation of Implantable Cardioverter-Defibrillator (ICD)

  • This measure provides hospital specific risk-standardized rates of procedural complications following the implantation of an Implantable Cardioverter-Defibrillator (ICD) in patients at least 65 years of age. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) Electrophysiology Device Implant Registry (EPDI - formerly the ICD Registry) for risk adjustment linked with administrative claims data using indirect patient identifiers to identify procedural complications.

    CBE ID
    0694

Hospital-Level, Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

  • The measure estimates a hospital-level risk-standardized complication rate (RSCR) associated with elective primary THA and/or TKA procedures for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage [MA]) aged 65 and older. The outcome (complication) is defined as any one of the specified complications occurring from the date of index admission to up to 90 days after the index admission. Complications are counted in the measure only if they occur during the index hospital admission or during a readmission.

    CBE ID
    1550

Hospital-Wide 30-Day, All-Cause, Unplanned Readmission Rate (HWR) for the Merit-Based Incentive Payment System (MIPS) Eligible Clinician Groups

  • The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), and assesses each group’s readmission rate.

    CBE ID
    3495

Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Service (HCBS) Participants

  • The Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Participants measure is a risk-adjusted, state-level measure that assesses rates of hospital admissions for ambulatory care sensitive conditions per 1,000 Medicaid HCBS participants aged 18 years and older. This measure has three rates reported for potentially avoidable inpatient hospital admissions:

    1. Chronic Conditions
    2. Acute Conditions
    3. Chronic and Acute Conditions Composite
    CBE ID
    4490

Hybrid Hospital‐Wide (All‐Condition, All‐Procedure) Risk‐Standardized Mortality Measure with Claims and Electronic Health Record Data

  • Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Claims and Electronic Health Record Data measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date for Medicare fee-for-service and Medicare Advantage patients who are between the ages of 65 and 94. 

    CBE ID
    3502e

Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

  • The Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia. Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms.

    CBE ID
    4545e