Quality Improvement (Internal to the specific organization)

Percentage of ASC admissions experiencing a fall in the ASC.

All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.
(Total number of falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

This measure identifies patients 2 years of age and older with acute otitis externa who were or were not prescribed systemic antimicrobial therapy.

This measure identifies patients with an emergency medicine visit for non-traumatic chest pain that had an ECG done as part of their evaluation.

This measure identifies patients with an emergency medicine visit for syncope that had an ECG done as part of their evaluation.

This measure identifies patients with hypertension (HTN) that had a serum creatinine in last 12 reported months

Percentage of vulnerable adults admitted to ICU who survive at least 48 hours who have their care preferences documented within 48 hours OR documentation as to why this was not done.

Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed

Patient(s) with a recent emergency room encounter for a transient cerebral ischemic event that had any physician visit within 14 days of the acute event.