Outcome-Focused

Percentage of patients 18 years of age or older without carotid territory neurologic or retinal symptoms within 120 days immediately proceeding carotid angioplasty and stent (CAS) placement who experience stroke or death during their hospitalization for this procedure. This measure is proposed for both hospitals and individual interventionalists. This measure is currently reported by the Vascular Quality Initiative (VQI) Registry.

Percentage of patients age 18 or older without carotid territory neurologic or retinal symptoms within the one year immediately preceding carotid endarterectomy (CEA) who experience stroke or death following surgery while in the hospital. This measure is proposed for both hospitals and individual surgeons. This measure is presently reported by the Vascular Quality Initiative (VQI) registry.

Percentage of laboratory potassium samples drawn in the emergency department (ED) with hemolysis.

Practice Environment Scale-Nursing Work Index (PES-NWI) is a survey based measure of the nursing practice environment completed by staff registered nurses; includes mean scores on index subscales and a composite mean of all subscale scores.

Stage III, IV, or unstageable pressure ulcers (secondary diagnosis) per 1,000 surgical and medical discharges among patients 17 years of age and younger. Discharges are grouped by risk category. Includes metrics for discharges grouped by risk category. Excludes neonates; stays less than three (3) days; obstetric discharges; discharges with diseases of the skin; and discharges with principal diagnosis or secondary diagnosis present on admission for Stage III, IV or unstageable pressure ulcer.

Percentage of adult dialysis patients with a 3-month rolling average of total uncorrected calcium (serum or plasma) greater than 10.2 mg/dL (hypercalcemia)

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).

In-hospital deaths per 1,000 pediatric heart surgery admissions among patients with congenital heart disease ages 17 years and younger.

Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA)who are discharged alive. This measure is proposed for both hospitals and individual providers. At present, this measure is reported via the Vascular Quality Initiative (VQI) Registry.

Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay were admitted to an acute care hospital during the 30 days following the start of the home health stay.