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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Counseling for Women of Childbearing Potential with Epilepsy

  • All female patients of childbearing potential (12–44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    CBE ID
    1814

Cultural Competency Implementation Measure

  • The Cultural Competence Implementation Measure is an organizational survey designed to assist healthcare organizations in identifying the degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as their adherence to 12 of the 45 NQF-endorsed® cultural competency practices prioritized for the survey. The target audience for this survey includes healthcare organizations across a range of health care settings, including hospitals, health plans, community clinics, and dialysis organizations.

    CBE ID
    1919

Death Rate among Surgical Inpatients with Serious Treatable Complications (PSI 04)

  • In-hospital deaths per 1,000 surgical discharges, among patients ages 18 through 89 years or obstetric patients, with serious treatable complications (shock/cardiac arrest, sepsis, pneumonia, deep vein thrombosis/ pulmonary embolism or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility. A risk-adjusted rate is available. The risk-adjusted rate of PSI 04 relies on stratum-specific risk models.

    CBE ID
    0351

Dehydration Admission Rate (PQI 10)

  • Admissions with a principal diagnosis of dehydration per 100,000 population, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

    [NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

    CBE ID
    0280

Depression Assessment Conducted

  • Percent of patients who were screened for depression (using a standardized depression screening tool) at start or resumption of home health care

    CBE ID
    0518

Depression Assessment with PHQ-9/ PHQ-9M

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during a four month measurement period.

    CBE ID
    0712

Depression Remission at Six Months

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.

    CBE ID
    0711