Quality Improvement (Internal to the specific organization)

Goal:

This process measure seeks to capture follow up after asthma-related emergency department (ED) visits for children with asthma after discharge from the ED, as recommended by the NHLBI 2007 guidelines. This measure assesses the percentage of asthma-related ED visits for children ages 3-21 with a follow-up visit with a primary care clinician or an asthma subspecialist within 14 days of discharge from the ED, within the reporting year, for patients who are enrolled in the health plan for two consecutive months following the ED visit. 

This measure scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.

This measure scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.

This measure scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of PNA for three types of events: readmissions, ED visits and evaluation and management (E&M) services.

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

Number of rehospitalizations occurring within 30 days of discharge from an acute care hospital (prospective payment system (PPS) or critical access hospital (CAH)) per 1000 FFS Medicare beneficiaries at the state and community level by quarter and year.

The 30-Day Risk Standardized All-Cause Emergency Department Visit Following an Inpatient Psychiatric Facility (IPF) Discharge (IPF ED Visit) measure assesses the proportion of patients ages 18 and older with an emergency department (ED) visit, including observation stays, for any cause, within 30 days of discharge from an IPF, without subsequent admission. The IPF ED Visit measure is an outcome-based measure. 

30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which all adult cancer patients covered as Fee-for-Service Medicare beneficiaries have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.”

In-hospital deaths per 1,000 discharges with abdominal aortic aneurysm (AAA) repair, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]