Patient-and Caregiver-Focused

In-hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

The PointRight Pro Long Stay Hospitalization Measure is an MDS-based, risk-adjusted measure of the rate of hospitalization of long-stay patients (also known as “residents”) of skilled nursing facilities (SNFs) averaged across the year, weighted by the number of stays in each quarter.

Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases per 1,000 elective surgical discharges for patients ages 18 years and older.

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.

Percent of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery.

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 patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
Normal Parameters: Age 18 and older BMI >= 18.5 and < 25 kg/m2

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter