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Safety

Plan All-Cause Readmissions (PCR)

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:

1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission

*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

CBE ID
1768

Pneumonia Mortality Rate (IQI #20)

In-hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[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.]

CBE ID
0231

Preoperative Beta Blockade

Percent of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery.

CBE ID
0127

Pressure Ulcer Rate (PDI 2)

Stage III, IV, or unstageable pressure ulcers (secondary diagnosis) per 1,000 surgical and medical discharges among patients 17 years of age and younger. Discharges are grouped by risk category. Includes metrics for discharges grouped by risk category. Excludes neonates; stays less than three (3) days; obstetric discharges; discharges with diseases of the skin; and discharges with principal diagnosis or secondary diagnosis present on admission for Stage III, IV or unstageable pressure ulcer.

CBE ID
0337

Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

CBE ID
2726

Proportion of Days Covered (PDC): 3 Rates by Therapeutic Category

The percentage of individuals 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80 percent during the measurement year.

Report a rate for each of the following:
• Diabetes All Class (PDC-DR)
• Renin Angiotensin System Antagonists (PDC-RASA)
• Statins (PDC-STA)

A higher rate indicates better performance.

CBE ID
0541

Proportion of patients with a chronic condition that have a potentially avoidable complication during a calendar year.

Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months.

CBE ID
0709

Quarterly Reporting of COVID-19 Vaccination Coverage among Healthcare Personnel

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

CBE ID
3636