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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Participation in a Systematic National Dose Index Registry

  • Participation in a multi-center, standardized data collection and feedback program that will establish national dose index benchmarks for designated examinations. The registry will eventually provide a comparison of practice or facility dose indices such as CTDIvol and DLP for specified examinations relative to national and regional benchmarks. Data is captured electronically from the images of CT examinations using Digital Imaging and Communications in Medicine (DICOM) standards and the Integrating the Healthcare Enterprise (IHE) Radiation Exposure Monitoring (REM) profile.

    CBE ID
    0740

Patient Burn

  • Percentage of ASC admissions experiencing a burn prior to discharge

    CBE ID
    0263

Patient Fall

  • Percentage of ASC admissions experiencing a fall in the ASC.

    CBE ID
    0266

Patient Fall Rate

  • All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.
    (Total number of falls / Patient days) X 1000

    Measure focus is safety.
    Target population is adult acute care inpatient and adult rehabilitation patients.

    CBE ID
    0141

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

  • This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

    CBE ID
    4210