Quality Improvement (Internal to the specific organization)

Inpatients age 65 years and older and 5-64 years of age who have a high risk condition who are screened for Pneumococcal Vaccine status and vaccinated prior to discharge if indicated.

Percent of nursing home/skilled nursing facility residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period.

Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.

In-hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

PointRight OnPoint-30 is an all-cause, risk adjusted rehospitalization measure. It provides the rate at which all patients (regardless of payer status or diagnosis) who enter skilled nursing facilities (SNFs) from acute hospitals and are subsequently rehospitalized during their SNF stay, within 30 days from their admission to the SNF.

The PointRight Pro Long Stay Hospitalization Measure is an MDS-based, risk-adjusted measure of the rate of hospitalization of long-stay patients (also known as “residents”) of skilled nursing facilities (SNFs) averaged across the year, weighted by the number of stays in each quarter.

Percentage of persons > 13 years of age with diagnosed HIV infection who are virally suppressed in the measurement year.

This measure identifies patients with ST elevation MI (STEMI), or non-ST elevation MI (NSTEMI) plus a history of hypertension, heart failure and/or diabetes prior to the measurement year who are taking an ACEI or an ARB during the measurement year.

Percentage of abdominopelvic surgery cases with reclosure of postoperative disruption of abdominal wall.

Percentage of abdominopelvic surgery cases with reclosure of postoperative disruption of abdominal wall.