Quality Improvement (Internal to the specific organization)

Percentage of intensive care patients with central lines for whom all
elements of the central line bundle are documented and in place.
The central line bundle elements include:
•Hand hygiene
•Maximal barrier precautions upon insertion
•Chlorhexidine skin antisepsis
•Optimal catheter site selection, with avoidance of the femoral vein for central venous access in patients 18 years and older
•Daily review of line necessity with prompt removal of unnecessary lines

The Activity Measure for Post Acute Care (AM-PAC) is a functional status assessment instrument developed specifically for use in facility and community dwelling post acute care (PAC) patients. It was built using Item Response Theory (IRT) methods to achieve feasible, practical, and precise measurement of functional status (Hambleton 200, Hambleton 2005).

The Activity Measure for Post Acute Care (AM-PAC) is a functional status assessment instrument developed specifically for use in facility and community dwelling post acute care (PAC) patients. It was built using Item Response Theory (IRT) methods to achieve feasible, practical, and precise measurement of functional status (Hambleton 2000, Hambleton 2005).

Percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care.

The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:


Communication with Parent
1. Communication between you and your child’s nurses (3 items)

Measures how many times per week child 6-17 years exercises vigorously (based on AAP and CDC recommendations)

Assesses if children age 1-17 years have had a toothache, tooth decay or cavities in the past 6 months

The measure is designed to ascetain whether or not current insurance program coverage is adequate for the child´s health needs--whether the out of pocket expenses are reasonable; whether the child is limited or not in choice of doctors; and whether the benefits meet child´s healthcare needs.

Assesses how many medical preventive visits in a 12 month period, such as a physical exam or well-child check-up (does not include visits related to specific illnesses)

Assesses how many preventive dental visits during the previous 12 months