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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Signed Part C Individual Family Service Plan (IFSP) before 6 months of age

  • This measure assesses the proportion of infants with permanent hearing loss with an Individual Family Service Plan (IFSP) to receive intervention services under Part C of the Individuals with Disabilities Education Act (IDEA) that is signed by the time the infant is 6 months of age.

    CBE ID
    1361

SINC-Based Contraceptive Care, Non-Postpartum

  • Percentage of women who 1) received or had documented use of most or moderately effective contraception and 2) received a long-acting reversible contraceptive method during the calendar year. 

    To focus the measure  on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated during the year that they did not want these services, as well as those who are eligible for postpartum contraceptive services during the measurement period.

    CBE ID
    3699e

SINC-Based Contraceptive Care, Postpartum

  • Percentage of women 1) who received or had documented use of most or moderately effective contraception during the postpartum period (primary measure) and 2) received a long-acting reversible contraceptive method during the postpartum period (sub-measure). To focus the measure on the population of women interested in contraceptive services, the denominator excludes those individuals who did not receive or have documented use of a method if they indicated they did not want these services. 

     

    CBE ID
    3682e

Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract)

  • NSC-12.1 - Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit.

    NSC-12.2 - Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit.

    NSC-12.3 - Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit.

    CBE ID
    0204

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

  • The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

    CBE ID
    2510

Standardized Readmission Ratio (SRR) for dialysis facilities

  • The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

    CBE ID
    2496

Statin Prescribed at Discharge

  • Percent of acute myocardial infarction (AMI) patients who are prescribed a statin at hospital discharge.

    CBE ID
    0639