Highest Opportunity for Improvement

This measure assesses the number of staphylococcal and gram negative septicemias or bacteremias in high-risk newborns. This measure is a part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-03: Antenatal Steroids, PC-05: Exclusive Breast Milk Feeding; Beginning 1/1/2019 PC-06 Unexpected Complications in Term Newborns will be added).

PC-05 assesses the rate of newborns exclusively fed breast milk during the newborn´s entire hospitalization. This measure is part of a set of four nationally implemented measures that address perinatal care (PC-01: Elective Delivery, ePC-01: Elective Delivery; PC-02: Cesarean Birth, ePC-02: Cesarean Birth will be added as an eCQM 1/1/2020; PC-05: Exclusive Breast Milk Feeding, ePC-05: Exclusive Breast Milk Feeding; PC-06 Unexpected Complications in Term Newborns was added 1/1/2019).

Percentage of pediatric (< 18 years old) peritoneal dialysis patient-months whose delivered peritoneal dialysis dose was a weekly Kt/Vurea >= 1.8 (dialytic + residual)

This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
1. Impaired bed mobility or transfer
2. Comatose

This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period.

The measure reports the percentage of short-stay residents or patients who are assessed and appropriately given the seasonal influenza vaccine during the most recently-completed influenza season. The influenza vaccination season (IVS) is defined as beginning on October 1, or when the vaccine first becomes available*, and ends on March 31 of the following year. This measure is based on the NQF´s National Voluntary Standards for Influenza and Pneumococcal Immunizations.

The percentage of births with birthweight <2,500 grams

Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

Risk adjusted rate of intra and post procedure bleeding for all patients age 18 and over undergoing PCI.

Admissions for any-listed diagnosis of perforations or abscesses of the appendix per 1,000 admissions with any-listed appendicitis, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

[NOTE: The software provides the rate per hospital admission. However, common practice reports the measure as per 1,000 admissions. The user must multiply the rate obtained from the software by 1,000 to report cases per 1,000 admissions.]