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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Methotrexate: CBC within 12 weeks

  • This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a CBC test within 120 days (3 months + 1 month grace period) following the earliest observed methotrexate prescription claim

    CBE ID
    0598

Methotrexate: Creatinine within 12 weeks

  • This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a serum creatinine test in the 120 days (3 months + 1 month grace period) after the earliest observed methotrexate prescription claim.

    CBE ID
    0599

Methotrexate: LFT within 12 weeks

  • This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a liver function test (LFT) in the 120 days (3 months + 1 month grace period) following the earliest observed methotrexate prescription claim.

    CBE ID
    0597

MI - Use of Beta Blocker Therapy

  • The percentage of patients aged 18 years and older diagnosed with myocardial infarction (MI) who are taking a beta blocker

    CBE ID
    0613e

Minimizing Institutional Length of Stay

  • The proportion of admissions to an institutional facility (e.g., nursing facility, intermediate care facility for individuals with intellectual disabilities [ICF/IID]) for managed long-term services and support (MLTSS) plan enrollees that result in successful discharge to the community (community residence for 60 or more days) within 100 days of admission. This measure is reported as an observed rate and a risk-adjusted rate.

    CBE ID
    3457

Monitoring hemoglobin levels below target minimum

  • Percentage of all adult (>=18 years old) hemodialysis patients, peritoneal dialysis, and home hemodialysis patients with ESRD >=3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb <10.0 g/dL for a 3 month study period, irrespective of ESA use.

    CBE ID
    0370

National Healthcare Safety Network (NHSN) Antimicrobial Use Measure

  • This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN).

    CBE ID
    2720

National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU).
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

    CBE ID
    0138

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

    CBE ID
    0139