Outcome-Focused

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care.

The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:


Communication with Parent
1. Communication between you and your child’s nurses (3 items)

Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

The measure estimates a hospital-level 30-day hospital-wide risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94.

Risk-Standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).

Discharges with a principal diagnosis of community acquired bacterial pneumonia per 100,000 population, age 18 or older. Excludes sickle cell or hemoglobin-S admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mm Hg.

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is >9.0% during the measurement year.