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Outcome-Focused

Patient Fall Rate

All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.
(Total number of falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

CBE ID
0141

PC-02 Cesarean Birth

This measure assesses the rate of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth. 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).

CBE ID
0471

PC-04 Health Care-Associated Bloodstream Infections in Newborns

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).

CBE ID
1731

Pediatric Asthma Emergency Department Use

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.

CBE ID
3599

Percent of High Risk Residents with Pressure Ulcers (Long Stay)

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

CBE ID
0679

Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)

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.

CBE ID
0674

Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

This measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter.

CBE ID
0686

Percent of Residents Who Lose Too Much Weight (Long-Stay)

This measure reports the percentage of long-stay nursing home residents with a target Minimum Data Set (MDS) assessment (OBRA, PPS, Discharge) that indicates a weight loss of 5% or more of the baseline weight in the last 30 days or 10% or more of the baseline weight in the last 6 months, which is not a result of a physician-prescribed weight-loss regimen. The baseline weight is the resident’s weight closest to 30 or 180 days before the date of the target assessment. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

CBE ID
0689