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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Risk-Adjusted 30-Day All-Cause Readmission Rate

  • The existing NQF-endorsed measure provides a means for determining the risk-adjusted readmission rate for a selected adult target population and can be applied for any desired timeframe. Readmission rate is defined as the percentage of acute inpatient discharges during the measurement period followed by an acute inpatient admission for any diagnosis to any hospital within 30 days

    CBE ID
    0329

Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate

  • Risk-adjusted percentage of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.

    CBE ID
    2514

Risk-Adjusted Morbidity and Mortality for Esophagectomy for Cancer

  • Percentage of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer who developed any of the following postoperative conditions: bleeding requiring reoperation, anastomosis leak requiring medical or surgical treatment, reintubation, ventilation >48 hours, pneumonia, or discharge mortality

    CBE ID
    0460

Risk-Adjusted Morbidity and Mortality for Lung Resection for Lung Cancer

  • Percentage of patients greater than or equal to 18 years of age undergoing elective lung resection (Open or VATS wedge resection, segmentectomy, lobectomy, bilobectomy, sleeve lobectomy, pneumonectomy) for lung cancer who developed any of the following postoperative complications: reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, unexpected return to the operating room, myocardial infarction or operative mortality (death during the index hospitalization, regardless of timing, or within 30 days, regardle

    CBE ID
    1790

Risk-Adjusted Operative Mortality for CABG

  • Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

    CBE ID
    0119

Risk-Adjusted Postoperative Renal Failure

  • Percent of patients aged 18 years and older undergoing isolated CABG (without pre-existing renal failure) who develop postoperative renal failure or require dialysis

    CBE ID
    0114

Risk-Adjusted Stroke/Cerebrovascular Accident

  • Percent of patients aged 18 years and older undergoing isolated CABG who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

    CBE ID
    0131