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Accountable entity level (i.e., measure score) (e.g., criterion validity)

Valid for Measure Submission

30-Day Post-Operative Colon Surgery (COLO) and Abdominal Hysterectomy (HYST) Surgical Site Infection (SSI) Standardized Infection Ratio (SIR)

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

CBE ID
0753

30-Day Risk Standardized All-Cause Emergency Department Visit Following an Inpatient Psychiatric Facility Discharge

The 30-Day Risk Standardized All-Cause Emergency Department Visit Following an Inpatient Psychiatric Facility (IPF) Discharge (IPF ED Visit) measure assesses the proportion of patients ages 18 and older with an emergency department (ED) visit, including observation stays, for any cause, within 30 days of discharge from an IPF, without subsequent admission. The IPF ED Visit measure is an outcome-based measure. 

CBE ID
4190

30-Day Unplanned Readmissions for Cancer Patients

30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which adult cancer patients have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.”

CBE ID
3188

Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.

CBE ID
1879

Bereaved Family Survey - Performance Measure (BFS-PM) Score (%) for all Veteran Affairs Medical Center Inpatient Deaths

The Bereaved Family Survey-Performance Measure (BFS-PM) is an outcome measure that is used to assess overall quality of care in the last month of life.  Currently, the BFS is administered to the next-of-kin of all Veterans who die in a VA inpatient setting (i.e., acute units, intensive care units, inpatient hospice and palliative care units, and VA nursing homes) 4-6 weeks post-death. The BFS-PM is calculated using the global rating item included on the 20-item BFS that has separate versions for male and female Veterans and is available in English and Spanish.

CBE ID
1623

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

Breast Cancer Screening Recall Rates

The Breast Cancer Screening Recall Rates measure calculates the percentage of beneficiaries with mammography or digital breast tomosynthesis (DBT) screening studies that are followed by a diagnostic mammography, DBT, ultrasound, or magnetic resonance imaging (MRI) of the breast in an outpatient or office setting within 45 days.

CBE ID
4220

Cardiac Rehabilitation Patient Referral From an Inpatient Setting

Percentage of patients aged 18 years and older admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.

CBE ID
0642

Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.   SIR is reported annually and is calculated by dividing the number of observed CAUTIs into the number of predicted CAUTIs. 

 

CBE ID
0138