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Public Reporting

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Emergency Transfer Communication Measure

  • Percentage of all patients transferred from an Emergency Department to another healthcare facility whose medical record documentation indicated that all required information was communicated (sent) to the receiving facility within 60 minutes of transfer For all data elements, the definition of ‘sent’ includes the following:
    • Hard copy sent directly with the patient, or 
    • Sent via fax or phone within 60 minutes of patient departure, or
    • Immediately available via shared Electronic health record (EHR) or Health Information Exchange (HIE) (see definition below)

    CBE ID
    0291

ePC-02 Cesarean Birth

  • This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth.  

    CBE ID
    0471e

ePC-07 Severe Obstetric Complications

  • Hospital-level measure scores are calculated as a risk-adjusted proportion of the number of delivery hospitalizations for women who experience a severe obstetric complication, as defined by the numerator, by the total number of delivery hospitalizations in the denominator during the measurement period.

    CBE ID
    3687e

ESRD Dialysis Patient Life Goals Survey (PaLS)

  • The PaLS is used to generate a patient-level t-score that reflects patient-reported satisfaction with how well his/her/their facility is doing in discussing life goals with the patient as part of the treatment planning process.

    CBE ID
    3742

ESRD- HD Adequacy CPM III: Minimum Delivered Hemodialysis Dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 90 days or greater.

  • Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2 during the reporting period.

    CBE ID
    0250

ETG Based HIP/KNEE REPLACEMENT cost of care measure

  • The measure focuses on resources used to deliver episodes of care for patients who have undergone a Hip/Knee Replacement. Hip Replacement and Knee Replacement episodes are initially defined using the Episode Treatment Groups (ETG) methodology and describe the unique presence of the condition for a patient and the services involved in diagnosing, managing and treating the condition. The Procedure Episode Group (PEG) methodology uses the ETG results and further logic to creating a procedure episode that focuses on the Hip Replacement and Knee Replacement component of the care.

    CBE ID
    1609