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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

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Death Rate among Surgical Inpatients with Serious Treatable Complications (PSI 04)

  • 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.

    CBE ID
    0351

Depression Assessment Conducted

  • Percent of patients who were screened for depression (using a standardized depression screening tool) at start or resumption of home health care

    CBE ID
    0518

Depression Assessment with PHQ-9/ PHQ-9M

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during a four month measurement period.

    CBE ID
    0712

Depression Remission at Six Months

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.

    CBE ID
    0711

Depression Remission at Twelve Months

  • Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. 
    This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the denominator.

    CBE ID
    0710e

Depression Response at Six Months- Progress Towards Remission

  • Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate a response to treatment at six months defined as a PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment.

    CBE ID
    1884

Depression Response at Twelve Months- Progress Towards Remission

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who are progressing towards remission by achieving a response (PHQ-9 or PHQ-9M score reduced by 50% or greater) twelve months (+/- 60 days) after an index visit. 

    CBE ID
    1885

Developmental Screening in the First Three Years of Life

  • The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the first three years of life. This is a measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened by 12 months of age, by 24 months of age and by 36 months of age.

    CBE ID
    1448