Quality Improvement (Internal to the specific organization)

This measure describes the change in functional communication status subsequent to speech-language pathology treatment of patients who exhibit difficuty in swallowing.

This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older with neck impairments. The change in FS is assessed using the Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient, individual clinician, and clinic levels to assess quality.

The measure is the percentage of patients who achieve a 3-point increase in their Patient Activation Measure® (PAM®) survey score within 12 months. The outcome measure demonstrates how a clinician group performed in providing best care to its patients by quantifying the proportion of patients who had at least a 3-point score change. 

Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year

A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

GAPPS is a measure of the number of preventable adverse events per 1,000 patient-days among pediatric inpatients. It is designed to compare rates across institutions and over time. The GAPPS measure utilizes the GAPPS trigger tool to identify adverse events.

Admissions for a principal diagnosis of gastroenteritis, or for a principal diagnosis of dehydration with a secondary diagnosis of gastroenteritis per 100,000 population, ages 3 months to 17 years. Excludes cases transferred from another facility, cases with gastrointestinal abnormalities or bacterial gastroenteritis, and obstetric admissions.

The percentage of patients with in the overall and high risk population with gastroesophogeal reflux disease (GERD) with alarm symptoms who have had an upper gastrointestinal study. (2 separate Denominators)

This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.

Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)