Quality Improvement (Internal to the specific organization)

Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period (Please reference attached document labeled NQF_Stroke_PACs_Risk_Adjustment_2.16.10.xls, tabs labeled CIP_Index PAC_Stays and CIP_PAC_Readmission). We define PACs during each time period as one of three types:

(A) PACs during the Index Stay (Hospitalization):

Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life

Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months.

Brief Description of Measure: Percent of adult population aged 18+ years with Community Acquired Pneumonia who are followed for one-month, and have one or more potentially avoidable complication (PAC) during the episode time window. Please reference the attached document labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls, in the tab labeled PACS I-9 & I-10 for a list of code definitions of PACs relevant to pneumonia.

Percentage of patients who died from cancer with more than one hospitalization in the last 30 days of life

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate

Percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT)

Percentage of children from 3.00 to 17.99 years of age seen for a pediatric well child visit who have a Pediatric Symptom Checklist (PSC) Tool administered as a component of that visit.