Quality Improvement (Internal to the specific organization)

The measure calculates a skilled nursing facility’s (SNFs) average change in self care for patients admitted from a hospital who are receiving therapy. The measure calculates the average change in self care score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the self care subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment.

This measure calculates a casemix-adjusted inpatient average length of stay (ALOS) for medical and surgical admissions for Commercial and Medicare populations. The measure can be reported at the hospital level or the service category level (medical vs. surgical).

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.   SIR is reported annually and is calculated by dividing the number of observed CAUTIs into the number of predicted CAUTIs. 

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

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

Annual risk-adjusted standardized infection ratio (SIR) of central line-associated bloodstream infections (CLABSI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, and long-term acute care hospitals. SIR is reported annually and is calculated by dividing the number of observed CLABSIs by the number of predicted CLABSIs.   

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