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Highest Opportunity for Improvement

Quarterly Reporting of COVID-19 Vaccination Coverage among Healthcare Personnel

  • This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

    The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

    CBE ID
    3636

Retained Surgical Item or Unretrieved Device Fragment Count (PDI 03)

  • The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 17 years and younger. Excludes normal newborns, newborns with birth weight less than 500 grams, cases with principal diagnosis of retained surgical item or unretrieved device fragment, cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission, and obstetric cases.

    CBE ID
    0362

Retained Surgical Item or Unretrieved Device Fragment Count (PSI 05)

  • The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients. Excludes cases with principal diagnosis of retained surgical item or unretrieved device fragment and cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

    CBE ID
    0363

Risk Adjusted Colon Surgery Outcome Measure

  • This is a hospital based, risk adjusted, case mix adjusted morbidity and mortality aggregate outcome measure of adults 18+ years undergoing colon surgery.

    CBE ID
    0706