Safety

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation (AF) ablation.

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

This patient-reported outcome-based performance measure uses the same measure specifications as the NQF-endorsed (NQF # 3559) hospital-level risk-standardized improvement rate (RSIR) following elective primary THA/TKA with the following exception: this measure attributes the outcome to a clinician or clinician group. Specifically, this measure will estimate a clinician-level and/or a clinician group-level RSIR following elective primary THA/TKA for Medicare fee-for-service (FFS) patients 65 years of age and older.

0-100 measure of cross-cultural communication related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

In-hospital deaths per 1,000 discharges for low mortality (< 0.5%) Diagnosis Related Groups (DRGs) among patients ages 18 years and older or obstetric patients. Excludes cases with trauma, cases with cancer, cases with an immunocompromised state, and transfers to an acute care facility.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography (MRA), neck computerized tomographic angiography (CTA), neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement

Percentage of all patients transferred from an Emergency Department to another healthcare facility whose medical record documentation indicated that all required information was communicated (sent) to the receiving facility within 60 minutes of transfer For all data elements, the definition of ‘sent’ includes the following:
• Hard copy sent directly with the patient, or 
• Sent via fax or phone within 60 minutes of patient departure, or
• Immediately available via shared Electronic health record (EHR) or Health Information Exchange (HIE) (see definition below)

This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for acute myocardial infarction (AMI) to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients hospitalized with AMI by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

The measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for HF to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients who had a HF hospitalization by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.