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Valid for Measure Submission

Bloodstream Infection in Hemodialysis Outpatients

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

CBE ID
1460

Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers

This measure was developed to improve the quality of care delivered to patients undergoing general surgery procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of return to a hospital for an acute, unplanned hospital visit within seven days of qualified general surgery procedures performed at an ambulatory surgical center (ASC) among Medicare Fee-For-Service (FFS) patients aged 65 years and older.

CBE ID
3357

Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Measures

The Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey consists of 19 measures that assess the experiences of Medicaid participants’ age 18 and older receiving long-term services and supports (LTSS). The measures report a case-mix adjusted top-box score. Measure scores are calculated based on participant responses to a cross-disability survey about their experiences with the LTSS they receive in the community, delivered through a Medicaid-funded HCBS program.

CBE ID
2967

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 Visits after Hospital Outpatient Surgery

Hospital Visits after Hospital Outpatient Surgery measures facility-level risk-standardized rate of acute, unplanned hospital visits within 7 days of a procedure performed at a hospital outpatient department (HOPD) among Medicare Fee-For-Service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. 

CBE ID
2687

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

CBE ID
4210