No

Proportion of SAH and ICH stroke patients age 18 years or older for whom a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is performed prior to surgical intervention (e.g., clipping, coiling, or any surgical intervention) in patients undergoing surgical intervention and documented in the medical record; OR, documented within 6 hours of arrival at the hospital emergency department in patients who do not undergo surgical intervention.

Proportion of subarachnoid hemorrhage (SAH) patients age 18 years and older for whom nimodipine treatment was administered within 24 hours of arrival at this hospital.

This is the sixth measure in a set of measures developed for Joint Commission Comprehensive Stroke Certification. Although it is not required that these measures are reported in conjunction with each other, The Joint Commission develops measures in sets in order to provide as comprehensive a view of quality for a particular clinical topic as possible.

The Cultural Competence Implementation Measure is an organizational survey designed to assist healthcare organizations in identifying the degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as their adherence to 12 of the 45 NQF-endorsed® cultural competency practices prioritized for the survey. The target audience for this survey includes healthcare organizations across a range of health care settings, including hospitals, health plans, community clinics, and dialysis organizations.

The University of California, Irvine (UCI) implemented and tested a CVD risk assessment tool that immediately identifies patients who are at increased risk for CVD or developing CVD. This tool can be integrated into the electronic health record (EHR) system. 

The CVD Risk Assessment Measure represents the proportion of pregnant and postpartum individuals assessed for CVD risk using a standardized tool at the clinic and facility levels of health care service delivery. The CVD risk assessment identifies pregnant and postpartum individuals without an existing CVD diagnosis who may have cardiovascular disease (CVD) or are at an increased risk of developing CVD, thus necessitating further evaluation. 

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.

Percentage of surgical inpatients with complications of care whose status is death

In-hospital deaths per 1,000 surgical discharges, among patients ages 18 through 89 years or obstetric patients, with serious treatable complications (shock/cardiac arrest, sepsis, pneumonia, deep vein thrombosis/ pulmonary embolism or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility. A risk-adjusted rate is available. The risk-adjusted rate of PSI 04 relies on stratum-specific risk models.