Quality Improvement (Internal to the specific organization)

Percentage of patients treated for bipolar disorder who are assessed for diabetes within 16 weeks after initiating treatment with an atypical antipsychotic agent.

Percentage of patients treated for bipolar disorder with evidence of level-of-function evaluation at the time of the initial assessment and again within 12 weeks of initiating treatment

Percentage of newborn discharges with an ICD-9-CM diagnosis code of birth trauma in a one-year time period.

Percentage of pneumonia patients 18 years of age and older who have had blood cultures performed in the emergency department prior to initial antibiotic received in hospital

The percentage of adolescents 13 years of age who had a blood pressure screening with results during the measurement year or the year prior to the measurement year.

The percentage of adolescents 18 years of age who had a blood pressure screening with results during the measurement or the year prior to the measurement year.

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

Percentage of adults 18 years old or older with valid BMI documentation in the past 24 month.

The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).

Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS and used in the Physician Quality Reporting System.

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.