Professional Certification or Recognition Program

Percentage of actively enrolled home-based primary care and palliative care patients who receive an ADL and IADL assessment. 

*Basic ADLs must include but are not limited to: bathing, transferring, toileting, and feeding; Instrumental ADLs (IADL) must include but are not limited to: telephone use and managing own medications

This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time

All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

(Total number of injury falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

Percentage of patients with a solid malignant tumor or lymphoma who had a febrile neutropenia (FN) risk assessment completed and documented in the medical record prior to the first cycle of intravenous chemotherapy

The percentage of adults 18 years of age and older who self-report receiving an influenza vaccine within the measurement period. This measure is collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, and commercial populations. It is reported as two separate rates stratified by age: 18-64 and 65 years of age and older.

Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart

Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period

Percentage of patients with advanced chronic disease (CKD4 or 5) or end-stage renal disease (ESRD) undergoing open surgical implantation of permanent hemodialysis access who receive an autogenous arterial venous fistula(AVF).

The percentage of children aged 5 to 17 years of age with diabetes (type 1 and type 2) that had a Hemoglobin A1c (HbA1c) test during the measurement year.