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Person or encounter-level (reliability and validity) methodology and results (if available)

Valid for Measure Submission

Global Malnutrition Composite Score

  • This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

    CBE ID
    3592e

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 Harm – Postoperative Respiratory Failure

  • This electronic clinical quality measure (eCQM) assesses the proportion of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF).

    CBE ID
    4130e

Kidney Health Evaluation

  • Percentage of patients aged 18-85 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the 12-month measurement period

    CBE ID
    4315e

Oncology: Medical and Radiation – Pain Intensity Quantified

  • This measure looks at the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

     

    This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients with a diagnosis of cancer who are also currently receiving chemotherapy or radiation therapy during the measurement period. 

     

    CBE ID
    0384e

Oncology: Medical and Radiation – Pain Intensity Quantified

  • This measure looks at the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified. This measure is to be submitted at each denominator eligible visit occurring during the performance period for patients with a diagnosis of cancer who are seen during the performance period / measurement period. The time period for data collection is intended to be 12 consecutive months.

     

    CBE ID
    0384

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

Safe Use of Opioids – Concurrent Prescribing

  • Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge.

    CBE ID
    3316e