Other

The number per 1,000 livebirths of <1500g infants delivered at hospitals not appropriate for that size infant.

Percentage of Surgical patients greater than 18 years of age with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.

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

Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months

Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease (ESRD) with a catheter after 90 days on hemodialysis who are seen/evaluated by a vascular surgeon or other surgeon qualified in the area of vascular access for permanent vascular access at least once during the 12-month reporting period.

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

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.

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

Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that the entire vital signs record was communicated to the receiving FACILITY within 60 minutes of departure

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed