Outcome-Focused

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.

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.

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.