Percentage of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure.
Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool
Documents the extent to which a provider uses certified/qualified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data into the EHR as discrete searchable data elements.
Documents the extent to which a provider uses a certified/qualified electronic health record (EHR) system capable of enhancing care management at the point of care. To qualify, the facility must have implemented processes within their EHR for disease management that incorporate the principles of care management at the point of care which include:
a. The ability to identify specific patients by diagnosis or medication use
b. The capacity to present alerts to the clinician for disease management, preventive services and wellness
The measure is a PRE-PM, which calculates the percentage of contraceptive care patients who give a “top box” score for their experience of contraceptive counseling. The measure is a four-question survey which asks patients about key components of patient-centered counseling, including respect and adequate information. A “top box” score is defined as a response which gives the highest score for each of the four questions. Respondents give answers evaluating the quality of contraceptive care they received in the past six months.
The measure calculates the percentage of family or designated responsible party for long stay residents (i.e., residents living in the facility for 100 days or more), who are satisfied. This consumer reported outcome measure is based on the CoreQ: Long-Stay Family questionnaire that has three items.
The measure calculates the percentage of long-stay residents, those living in the skilled nursing facility for 100 days or more, who are satisfied. This patient reported outcome measure is based on the CoreQ: Long-Stay Resident questionnaire that is a three-item questionnaire.
Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or have had female sterilization from the denominator.
This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.
This facility-level measure estimates an all-cause, unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease.
The performance period for the measure is 24 months.