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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Pediatric weight documented in kilograms

  • Percentage of emergency department visits by patients < 18 years of age with a current weight documented in kilograms in the ED electronic health record; measure to be reported each month.

    CBE ID
    0504

Percent of High Risk Residents with Pressure Ulcers (Long Stay)

  • This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
    1. Impaired bed mobility or transfer
    2. Comatose

    CBE ID
    0679

Percent of hospitalized pneumonia patients with chest imaging confirmation

  • The chest imaging-confirmed measure of pneumonia diagnosis is a process measure of inpatient hospitalizations that identifies the proportion of adult patients hospitalized patients with a discharge diagnosis of pneumonia and who received systemic or oral antimicrobials at any time during admission who received chest imaging that supported the diagnosis of pneumonia, as recommended by clinical practice guidelines.  The measure applies to a target population of adult hospitalized patients.

    CBE ID
    4440e

Percent of Low Risk Residents Who Lose Control of Their Bowels or Bladder (Long-Stay)

  • This measure updates CMS’ MDS 2.0 QM on bowel and bladder control. It is based on data from Minimum Data Set (MDS) 3.0 assessments of low risk long-stay nursing facility residents (those whose cumulative days in the facility is greater than 100 days). This measure reports the percent of long-stay residents with a selected target assessment who are frequently or always bladder or bowel incontinent as indicated on the target MDS assessment (OBRA, PPS or discharge) during the selected quarter (3-month period).

    CBE ID
    0685

Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Long-Stay)

  • This measure is based on data from MDS 3.0 assessments of long-stay nursing facility residents. The measure reports the percentage of all long-stay residents 5 years and older who were assessed and appropriately given the Pneumococcal Vaccination as reported on the target MDS assessment (OBRA, PPS or discharge) during the 12-month reporting period. This proposed measure is harmonized with NQF’s quality measure on Pneumococcal Immunizations.(1) The MDS 3.0 definitions have been changed to conform to the NQF standard.

    CBE ID
    0683

Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (long stay)

  • This measure reports the percentage of long-stay residents, 180 days of age and older, who were in a nursing facility for at least one day during the most recently completed influenza vaccination season (IVS), and who were assessed and appropriately given the seasonal influenza vaccine . The IVS is defined as beginning on October 1 and ends on March 31 of the following year.

    CBE ID
    0681

Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)

  • This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period.

    CBE ID
    0674