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Outcome-Focused

Pressure Ulcer Rate (PDI 2)

  • 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.

    CBE ID
    0337

Proportion of patients with hypercalcemia

  • 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)

    CBE ID
    1454

Quarterly Reporting of COVID-19 Vaccination Coverage among Healthcare Personnel

  • 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).

    CBE ID
    3636

Rehospitalization During the First 30 Days of Home Health

  • 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.

    CBE ID
    2380

Retained Surgical Item or Unretrieved Device Fragment Count (PDI 03)

  • 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.

    CBE ID
    0362

Retained Surgical Item or Unretrieved Device Fragment Count (PSI 05)

  • 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.

    CBE ID
    0363