Lowest Data Collection Burden

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Categories, a multi-institutional validated risk stratification tool

Percentage of enrolled children under age 21 years who received a comprehensive or periodic oral evaluation within the reporting year.

In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

The number of hospital discharges with a procedure of partial or total pancreatic resection for patients 18 years and older or obstetric patients. Excludes acute pancreatitis admissions.

Participation in at least one multi-center, standardized data collection and feedback program for pediatric and congenital heart surgery that provides benchmarking of the physician’s data relative to national and regional programs and uses process and outcome measures.

Participation in a multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.

The PSI 90 composite measure summarizes patient safety across multiple indicators for the CMS Medicare fee-for-service population.

This measure estimates the rate of emergency department visits for children ages 3 – 21 who are being managed for identifiable asthma, using specified definitions. The measure is reported in visits per 100 child-years.

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