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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

PACE-Acquired Pressure Ulcer/Injury Prevalence Rate

  • Prevalence of PACE-acquired pressure ulcers/injuries (Stages 3, 4, unstageable, and deep tissue injury) among PACE participants in a quarter, expressed as persons with 1 or more pressure ulcers/injuries divided by the number of participants on the PACE organization’s census who resided in a home setting (home or assisted living facility)for at least one day during the quarter.

    CBE ID
    3000

Pain Assessment Conducted

  • Percentage of home health episodes of care in which the patient was assessed for pain, using a standardized pain assessment tool, at start/resumption of care.

    CBE ID
    0523

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