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Quality Improvement (Internal to the specific organization)

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Valid for Maintenance

ePC-07 Severe Obstetric Complications

  • Hospital-level measure scores are calculated as a risk-adjusted proportion of the number of delivery hospitalizations for women who experience a severe obstetric complication, as defined by the numerator, by the total number of delivery hospitalizations in the denominator during the measurement period.

    CBE ID
    3687e

ESRD- HD Adequacy CPM III: Minimum Delivered Hemodialysis Dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 90 days or greater.

  • Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2 during the reporting period.

    CBE ID
    0250

ETG Based HIP/KNEE REPLACEMENT cost of care measure

  • The measure focuses on resources used to deliver episodes of care for patients who have undergone a Hip/Knee Replacement. Hip Replacement and Knee Replacement episodes are initially defined using the Episode Treatment Groups (ETG) methodology and describe the unique presence of the condition for a patient and the services involved in diagnosing, managing and treating the condition. The Procedure Episode Group (PEG) methodology uses the ETG results and further logic to creating a procedure episode that focuses on the Hip Replacement and Knee Replacement component of the care.

    CBE ID
    1609

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Group Level)

  • This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

    CBE ID
    3662e

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

  • This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

    CBE ID
    3633e

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility Level)

  • This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

    CBE ID
    3663e

External Beam Radiotherapy for Bone Metastases

  • This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.

    CBE ID
    1822