Professional Certification or Recognition Program

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types:

Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period (Please reference attached document labeled NQF_Stroke_PACs_Risk_Adjustment_2.16.10.xls, tabs labeled CIP_Index PAC_Stays and CIP_PAC_Readmission). We define PACs during each time period as one of three types:

(A) PACs during the Index Stay (Hospitalization):

Brief Description of Measure: Percent of adult population aged 18+ years with Community Acquired Pneumonia who are followed for one-month, and have one or more potentially avoidable complication (PAC) during the episode time window. Please reference the attached document labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls, in the tab labeled PACS I-9 & I-10 for a list of code definitions of PACs relevant to pneumonia.

Percentage of children from 3.00 to 17.99 years of age seen for a pediatric well child visit who have a Pediatric Symptom Checklist (PSC) Tool administered as a component of that visit.

Percentage of adult patients (aged 18 and over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed

Percentage of SUI surgeries for which cystoscopy was used during the surgical procedure to reduce complications

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug (DMARD) therapy within 12 months.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

This measure estimates a hospital-level risk standardized survival rate (RSSR) for adult patients aged 18 years and older who experience an in-hospital cardiac arrest.