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Statistical risk model with risk factors

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

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

Cross-Setting Discharge Function Score for Inpatient Rehabilitation Facilities

  • This outcome measure estimates the percentage of Inpatient Rehabilitation Facility (IRF) Medicare patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics. The measure includes patients who are 18 years of age or older and the timeframe for the measure is 12 months.

    CBE ID
    4630

Cross-Setting Discharge Function Score for Long-Term Care Hospitals

  • This outcome measure estimates the percentage of Long-Term Care Hospital (LTCH) patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients 18 years of age or older and the measure timeframe is 12 months.

    CBE ID
    4635

Cross-Setting Discharge Function Score for Skilled Nursing Facilities

  • This outcome measure estimates the percentage of Medicare Part A skilled nursing facility stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients who are 18 years of age or older and the measure timeframe is 12 months.

    CBE ID
    4640

Cross-Setting Discharge Function Score – for Home Health Agencies

  • This outcome measure estimates the percentage of Home Health (HH) Medicare patients (18+) who meet or exceed an expected discharge function score over a 12-month period.

    The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics.

    CBE ID
    4645

Days at Home for Patients with Complex, Chronic Conditions

  • 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.

    CBE ID
    4555

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

  • This measure was developed to improve the quality of care delivered to patients undergoing outpatient colonoscopy procedures. The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure, estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a colonoscopy procedure performed at a hospital outpatient department (HOPD) or ambulatory surgical center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and older.

    CBE ID
    2539