Quality Improvement (Internal to the specific organization)

Low birth weight (< 2,500 grams) infants per 1,000 newborns. Excludes transfers from other institutions.

[NOTE: The software provides the rate per newborn. However, common practice reports the measure as per 1,000 newborns. The user must multiply the rate obtained from the software by 1,000 to report admissions per 1,000 newborns.]

[NOTE: This indicator can be calculated in SAS QI Software Version 4.5 using either the PDI Module or the PQI #9 Standalone Module.]

The percentage of men aged 65 through 75 with history of tobacco use or men aged 60 years or more with a family history of abdominal aortic aneurysm (AAA)who were screened for AAA

Percentage of patients, aged 6-18 years old, treated with psychostimulant medication for the diagnosis of attention deficit hyperactivity disorder (ADHD) whose medical record contains documentation of follow-up visits at least twice a year that include height, weight, a discussion of medication, a discussion of school progress and a care plan.

The following components of this measure assess the management of urinary incontinence in older adults.

- Discussing Urinary Incontinence. The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who discussed their urinary leakage problem with a health care provider.

- Treatment of Urinary Incontinence. The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who treatment options for their current urine leakage problem.

Percentage of patients for whom there is documentation that a written asthma management plan was provided either to the patient or the patient’s caregiver OR, at a minimum, specific written instructions on under what conditions the patient’s doctor should be contacted or the patient should go to the emergency room

The percentage of children 6 months of age who had documentation of a maternal depression screening for the mother.

Percentage of all adult peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum calcium measured at least once within month

Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department

NQF #0496 calculates the median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department (ED). The measure is calculated using chart-abstracted data, on a rolling quarterly basis, and is publically reported in aggregate for one calendar year. The measure has been publically reported since 2013 as part of the ED Throughput measure set of the CMS’ Hospital Outpatient Quality Reporting (HOQR) Program.

Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with
Probable Cardiac Chest Pain).