Hospital: Acute Care Facility

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 Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.

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.

The Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia who receive an excess antibiotic duration. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level for both quality improvement and pay-for-performance.

This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

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.

PSI 90 is a composite of ten adverse event indicators that summarizes hospitals’ performance on patient safety for the CMS Medicare fee-for-service population. The timeframe used in the CMS Hospital Acquired Conditions Reduction Program (HACRP) and CareCompare public reporting are set within the Inpatient Prospective Payment Systems (IPPS) Final Rule annually. Typically, the performance periods use multiple months of claims data.

This measure estimates a hospital-level risk standardized survival rate (RSSR) for adult patients aged 18 years and older who experience an in-hospital cardiac arrest.

The Use of Pharmacotherapy for Opioid Use Disorder measure evaluates the percentage of Medicaid or Medicare-Medicaid participants, aged 18 years and older, who have been diagnosed with an opioid use disorder (OUD) who filled a prescription for, were administered, or dispensed, a Food and Drug Administration (FDA)-approved medication to treat or manage OUD during the measurement year.