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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Median Time to Pain Management for Long Bone Fracture

  • Median time from emergency department arrival to time of initial oral, intranasal or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).

    CBE ID
    0662

Medical Home System Survey (MHSS)

  • The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

    Composite 1: Patient-Centered Access
    Composite 2: Team-Based Care
    Composite 3: Population Health Management
    Composite 4: Care Management and Support
    Composite 5: Care Coordination and Care Transitions

    CBE ID
    1909

Medicare Spending Per Beneficiary – Post Acute Care Measure for Inpatient Rehabilitation Facilities

  • The Medicare Spending Per Beneficiary – Post Acute Care Measure for Inpatient Rehabilitation Facility (MSPB-PAC IRF) was developed to address the resource use domain of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This resource use measure is intended to evaluate each IRF’s efficiency relative to that of the national median IRF. Specifically, the measure assesses Medicare spending by the IRF and other healthcare providers during an MSPB episode.

    CBE ID
    3561

Medicare Spending Per Beneficiary – Post Acute Care Measure for Long-Term Care Hospitals

  • The Medicare Spending Per Beneficiary – Post Acute Care Measure for Long-Term Care Hospitals (MSPB-PAC LTCH) was developed to address the resource use domain of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This resource use measure is intended to evaluate each LTCH’s efficiency relative to that of the national median LTCH. Specifically, the measure assesses Medicare spending by the LTCH and other healthcare providers during an MSPB episode.

    CBE ID
    3562

Medication Reconciliation Post-Discharge (MRP)

  • The percentage of discharges during the first 11 months of the measurement year (e.g., January 1–December 1) for patients 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.

    CBE ID
    0554

Melanoma Coordination of Care

  • Percentage of patient visits, regardless of age, seen with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

    CBE ID
    0561

Melanoma: Continuity of Care – Recall System

  • Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month reporting period, into a recall system that includes:
    • A target date for the next complete physical skin exam , AND
    • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

    CBE ID
    0650