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Valid for Measure Submission

Monitoring hemoglobin levels below target minimum

  • Percentage of all adult (>=18 years old) hemodialysis patients, peritoneal dialysis, and home hemodialysis patients with ESRD >=3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb <10.0 g/dL for a 3 month study period, irrespective of ESA use.

    CBE ID
    0370

National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU).
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

    CBE ID
    0138

National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure

  • De.2. Brief description of measure
    Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (CAUTI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs) (excluding patients in neonatal ICUs [NICUs: Level II/III and Level III nurseries])
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0752

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

    CBE ID
    0139

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs)
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0754

Nursing Hours per Patient Day

  • NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    Measure focus is structure of care quality in acute care hospital units.

    CBE ID
    0205

Nursing Information

  • Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that nursing information was communicated to the receiving FACILITY within 60 minutes of departure

    CBE ID
    0296

Oncology: Radiation Dose Limits to Normal Tissues

  • Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

    CBE ID
    0382