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Inpatient/Hospital

Medication Continuation Following Inpatient Psychiatric Discharge

  • This measure assesses whether patients discharged from an inpatient psychiatric facility (IPF) with major depressive disorder (MDD), schizophrenia, or bipolar disorder filled a prescription for evidence-based medication within 2 days prior to discharge and 30 days post-discharge. This measure evaluates admissions over a two-year period.

    CBE ID
    3205

Medication Information

  • Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that medication information was communicated to the receiving FACILITY within 60 minutes of departure

    CBE ID
    0293

Medication Reconciliation on Admission

  • Percentage of patients for whom a designated PTA medication list was generated by referencing one or more external sources of PTA medications and for which all PTA medications have a documented reconciliation action by the end of Day 2 of the hospitalization.

    CBE ID
    3317

MI - Use of Beta Blocker Therapy

  • The percentage of patients aged 18 years and older diagnosed with myocardial infarction (MI) who are taking a beta blocker

    CBE ID
    0613e

Monitoring hemoglobin levels below target minimum

  • Percentage of all adult (>=18 years old) hemodialysis patients, peritoneal dialysis, and home hemodialysis patients with ESRD >=3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb <10.0 g/dL for a 3 month study period, irrespective of ESA use.

    CBE ID
    0370

MRI Lumbar Spine for Low Back Pain

  • This measure evaluates the percentage of magnetic resonance imaging (MRI) of the lumbar spine studies for low back pain performed in the outpatient setting where conservative therapy was not attempted prior to the MRI. Antecedent conservative therapy may include claim(s) for physical therapy in the 60 days preceding the lumbar spine MRI, claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine MRI, or claim(s) for evaluation and management at least 28 days but no later than 60 days preceding the lumbar spine MRI.

    CBE ID
    0514

Neonatal Blood Stream Infection Rate (NQI 03)

  • Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.

    CBE ID
    0478

Non-Emergent Coronary Artery Bypass Graft (CABG) Measure

  • The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a CABG procedure during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

    CBE ID
    3625

Nursing Hours per Patient Day

  • NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    Measure focus is structure of care quality in acute care hospital units.

    CBE ID
    0205