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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

  • Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge

    CBE ID
    0244

Stroke and Stroke Rehabilitation: Screening for Dysphagia

  • Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care

    CBE ID
    0243

STS Aortic Valve Replacement (AVR) + Coronary Artery Bypass Graft (CABG) Composite Score

  • The STS AVR+CABG Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1.

    CBE ID
    2563

STS Aortic Valve Replacement (AVR) Composite Score

  • STS AVR Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1. reoperations for any cardiac reason, 2.

    CBE ID
    2561

STS Individual Surgeon Composite Measure for Adult Cardiac Surgery

  • The STS Individual Surgeon Composite Measure for Adult Cardiac Surgery includes five major procedures (isolated CABG, isolated AVR, AVR+CABG, MVRR, MVRR+CABG) and comprises the following two domains:

    Domain 1 – Risk-Adjusted Operative Mortality
    Operative mortality is defined as death before hospital discharge or within 30 days of the operation.

    Domain 2 – Risk-Adjusted Major Morbidity
    Major morbidity is defined as the occurrence of any one or more of the following major complications:
    1. Prolonged ventilation,
    2. Deep sternal wound infection,

    CBE ID
    3030

STS Lobectomy for Lung Cancer Composite Score

  • The STS Lobectomy Composite Score comprises two domains:

    1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
    2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.

    CBE ID
    3294

STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score

  • The STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score measures surgical performance for MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF). To assess overall quality, the STS MVRR +CABG Composite Score comprises two domains consisting of six measures:

    Domain 1 – Absence of Operative Mortality

    CBE ID
    3032