Public Reporting

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.

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

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

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

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

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Categories, a multi-institutional validated risk stratification tool

The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:
• HbA1c less than 8.0 mg/dL
• Blood Pressure less than 140/90 mmHg
• On a statin medication, unless allowed contraindications or exceptions are present
• Non-tobacco user
• Patient with ischemic vascular disease is on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present

Information From 2015 Submission

Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis (peritoneal dialysis or home hemodialysis), or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.

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

Percentage of enrolled children under age 21 years who received a comprehensive or periodic oral evaluation within the reporting year.