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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

CoreQ: Long-Stay Resident Measure

  • The measure calculates the percentage of long-stay residents, those living in the facility for 100 days or more, who are satisfied (see: S.5 for details of the time-frame). This patient reported outcome measure is based on the CoreQ: Long-Stay Resident questionnaire that is a three item questionnaire.

    CBE ID
    2615

CoreQ: Short Stay Discharge Measure

  • The measure calculates the percentage of individuals discharged in a six month time period from a SNF, within 100 days of admission, who are satisfied (see: S.5 for details of the time-frame). This patient reported outcome measure is based on the CoreQ: Short Stay Discharge questionnaire that utilizes four items.

    CBE ID
    2614

Counseling for Women of Childbearing Potential with Epilepsy

  • All female patients of childbearing potential (12–44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    CBE ID
    1814

CSTK-01: National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients

  • Proportion of ischemic stroke patients age 18 years or older for whom an initial NIHSS score is performed prior to any acute recanalization therapy (i.e., intra-venous (IV) thrombolytic (t-PA) therapy, or intra-arterial (IA) thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion (MER) therapy) in patients undergoing recanalization therapy and documented in the medical record, or documented within 12 hours of arrival at the hospital emergency department in patients who do not undergo recanalization therapy.

    CBE ID
    2864

CSTK-03: Severity Measurement Performed for Subarachnoid Hemorrhage (SAH) and Intracerebral Hemorrhage (ICH) Patients (Overall Rate)

  • 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.

    CBE ID
    2866

CSTK-06: Nimodipine Treatment Administered

  • 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.

    CBE ID
    2863

Cultural Competency Implementation Measure

  • 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.

    CBE ID
    1919