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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Tracking of Clinical Results Between Visits

  • Documentation of the extent to which a provider uses a certified/qualified electronic health record (EHR) system to track pending laboratory tests, diagnostic studies (including common preventive screenings) or patient referrals. The Electronic Health Record includes provider reminders when clinical results are not received within a predefined timeframe.

    CBE ID
    0491

Transfusion Reaction Count (PDI 13)

  • The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 17 years and younger. Excludes cases with a principal diagnosis of transfusion reaction, cases with a secondary diagnosis of transfusion reaction that is present on admission, neonates, and obstetric cases.

    CBE ID
    0350

Transfusion Reaction Count (PSI 16)

  • The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 18 years and older or obstetric patients. Excludes cases with a principal diagnosis of transfusion reaction or cases with a secondary diagnosis of transfusion reaction that is present on admission.

    CBE ID
    0349

Tympanostomy Tube Hearing Test

  • This measure identifies the percentage of patients age 2 through 12 years with OME who received tympanostomy tube(s) insertion during the measurement year and had a hearing test performed within 6 months prior to the initial tube placement.

    CBE ID
    0587

Unexpected Newborn Complications in Term Infants

  • This is a hospital level performance score reported as the percent of infants with Unexpected Newborn Complications among full term newborns with no preexisting conditions, typically calculated per year.

    CBE ID
    0716

Urinary Incontinence: Assessment, Characterization, and Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

  • This is a clinical performance measure which assesses whether women age 65+ were provided appropriate treatment for urinary incontinence (UI). This measure has three rates:

    (A) Assessment for UI: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
    (B) Characterization of UI: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months

    CBE ID
    0098