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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Use of Pharmacotherapy for Opioid Use Disorder

  • The Use of Pharmacotherapy for Opioid Use Disorder measure evaluates the percentage of Medicaid or Medicare-Medicaid participants, aged 18 years and older, who have been diagnosed with an opioid use disorder (OUD) who filled a prescription for, were administered, or dispensed, a Food and Drug Administration (FDA)-approved medication to treat or manage OUD during the measurement year.

    CBE ID
    3400

Validated family-centered survey questionnaire for parents’ and patients’ experiences during inpatient pediatric hospital stay

  • This family-centered survey questionnaire consists of 68 questions that assess various aspects of care experiences during inpatient pediatric hospital stays. Questions can be used individually to measure specific performance but 35 rating questions can also be summarized into domain scores.

    The 68 questions of the survey can be divided into 3 groups:
    1. 26 background questions that mostly provide information for comparisons across different demographic and patient groups:

    CBE ID
    0725

Vascular Access—Functional Arteriovenous Fistula (AVF) or AV Graft or Evaluation for Placement

  • Percentage of end stage renal disease (ESRD) patients aged 18 years and older receiving hemodialysis during the 12-month reporting period and on dialysis >90 days who:

    1. have a functional autogenous AVF (defined as two needles used or a single-needle device [NOT one needle used in a two-needle device]) (computed and reported separately);

    2. have a functional AV graft (computed and reported separately); or

    CBE ID
    0251

Venous Thromboembolism Patients Recieving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

  • This measure assesses the number of patients diagnosed with confirmed venous thromboembolism (VTE) who received intravenous (IV) unfractionated heparin (UFH) therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. This measure is part of a set of six prevention and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Incidence of Potentially-Preventable VTE).

    CBE ID
    0374

Venous Thromboembolism Prophylaxis

  • This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

    CBE ID
    0371

Venouse Thromboembolism Patients with Antocoagulation Overlap Therapy

  • This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of Parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy.

    CBE ID
    0373

Ventilator Bundle

  • Percentage of intensive care unit patients on mechanical ventilation
    at time of survey for whom all five elements of the ventilator bundle are documented and in place. The ventilator bundle elements are:
    •Head of bed (HOB) elevation 30 degrees or greater (unless medically contraindicated)
    •Daily “”sedation interruption” and daily assessment of readiness to extubate •Peptic ulcer disease prophylaxis
    •Deep Venous Thrombosis prophylaxis
    •Daily oral care with Chlorhexidine

    CBE ID
    0302