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Valid for Measure Submission

National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU).
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

    CBE ID
    0138

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

    CBE ID
    0139

Oncology: Radiation Dose Limits to Normal Tissues

  • Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

    CBE ID
    0382

Oncology: Treatment Summary Communication – Radiation Oncology

  • Percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to the physician(s) providing continuing care and to the patient within one month of completing treatment

    CBE ID
    0381

Oncology: Cancer Stage Documented

  • Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have cancer staging documented using any standardized system or documentation that the cancer is metastatic in the medical record within one month of first office visit

    CBE ID
    0386

One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

  • Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received one-time screening for hepatitis C virus (HCV) infection

    CBE ID
    3059e

Optimal Vascular Care (Composite)

  • Measure Description: The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:
    • Blood pressure less than 140/90 mmHg
    • On a statin medication, unless allowed contraindications or exceptions are present
    • Non-tobacco user
    • On daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present

    Exclusions

    CBE ID
    0076

PACE Participant Fall Rate

  • The quarterly incidence rate of falls amongst PACE participants per 1,000 participant days.

    CBE ID
    3001