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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Pancreatic Resection Volume (IQI 2)

  • The number of hospital discharges with a procedure of partial or total pancreatic resection for patients 18 years and older or obstetric patients. Excludes acute pancreatitis admissions.

    CBE ID
    0366

Participation by a physician or other clinician in systematic clinical database registry that includes consensus endorsed quality measures

  • Participation in a systematic qualified clinical database registry involves:
    a. Physician or other clinician submits standardized data elements to registry
    b. Data elements are applicable to consensus endorsed quality measures
    c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry's clinical topic(s) and report on all patients eligible for the selected measures.
    d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians.

    CBE ID
    0493

Participation in a Practice-based or individual Quality Database Registry with a standard measure set.

  • This Registry should be capable of
    a. generating population based reports relating to published guideline goals or benchmarking data
    b. providing comparisons to the practitioner
    c. providing feedback that is related to guideline goals
    d. capturing data for one or more chronic disease conditions (i.e. diabetes) or preventive care measures (i.e. USPTF recommendations) for all patients eligible for the measures

    CBE ID
    0492

Participation in a Systematic National Dose Index Registry

  • Participation in a multi-center, standardized data collection and feedback program that will establish national dose index benchmarks for designated examinations. The registry will eventually provide a comparison of practice or facility dose indices such as CTDIvol and DLP for specified examinations relative to national and regional benchmarks. Data is captured electronically from the images of CT examinations using Digital Imaging and Communications in Medicine (DICOM) standards and the Integrating the Healthcare Enterprise (IHE) Radiation Exposure Monitoring (REM) profile.

    CBE ID
    0740

Patient Burn

  • Percentage of ASC admissions experiencing a burn prior to discharge

    CBE ID
    0263

Patient Education Awareness—Facility Level

  • Percentage of a physician´s end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

    CBE ID
    0324

Patient Education Awareness—Physician Level

  • Percentage of end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

    CBE ID
    0320