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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

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

Patient Fall

Percentage of ASC admissions experiencing a fall in the ASC.

CBE ID
0266

Patient Fall Rate

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.

CBE ID
0141