Highest Opportunity for Improvement

Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed.

The percentage of patients 18 years of age and older who were discharged from an inpatient setting with an acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) during the 12 months prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had documentation of routine use of aspirin or another antiplatelet during the measurement year.

Standardized morbidity ratio and observed minus expected measure for nosocomial bacterial infection after day 3 from birth in very low birth weight infants, defined as infants whose birth weights are between 501 and 1500 grams

Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amputation (except toe amputations) per 100,000 population, ages 18 years and older. Excludes any-listed diagnosis of traumatic lower-extremity amputation admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

This measure calculates the median time from emergency department arrival to time of transfer to another facility for acute coronary intervention.

The three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:

Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who received advice to quit during the measurement year.

The MSPB Hospital measure evaluates hospitals’ risk-adjusted episode costs relative to the risk-adjusted episode costs of the national median hospital. Specifically, the MSPB Hospital measure assesses the cost to Medicare for Part A and Part B services performed by hospitals and other healthcare providers during an MSPB Hospital episode, which is comprised of the periods 3-days prior to, during, and 30-days following a patient’s hospital stay. The MSPB Hospital measure is not condition specific and uses standardized prices when measuring costs.

This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN).

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.

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.