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Public Reporting

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Patient Burn

  • Percentage of ASC admissions experiencing a burn prior to discharge

    CBE ID
    0263

Patient Education Awareness—Facility Level

  • Percentage of a physician´s end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

    CBE ID
    0324

Patient Education Awareness—Physician Level

  • Percentage of end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

    CBE ID
    0320

Patient Fall

  • Percentage of ASC admissions experiencing a fall in the ASC.

    CBE ID
    0266

Patient Fall Rate

  • All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.
    (Total number of falls / Patient days) X 1000

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

    CBE ID
    0141

Patient Safety Indicator (PSI) 90: Patient Safety and Adverse Events Composite

  • PSI 90 is a composite of ten adverse event indicators that summarizes hospitals’ performance on patient safety for the CMS Medicare fee-for-service population. The timeframe used in the CMS Hospital Acquired Conditions Reduction Program (HACRP) and CareCompare public reporting are set within the Inpatient Prospective Payment Systems (IPPS) Final Rule annually. Typically, the performance periods use multiple months of claims data.

    CBE ID
    0531

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

  • This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

    CBE ID
    4210