Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

The Pediatric Symptom Checklist (PSC) is a brief parent-report questionnaire that is used to assess overall psychosocial functioning in children from 3 to 18 years of age. Originally developed to be a screen that would allow pediatricians and other health professionals to identify children with poor overall functioning who were in need of further evaluation or referral, the PSC has seen such wide use in large systems that it has increasingly been used as a quality indicator and as an outcome measure to assess changes in functioning over time.

Percentage of emergency department visits by patients < 18 years of age with a current weight documented in kilograms in the ED electronic health record; measure to be reported each month.

This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
1. Impaired bed mobility or transfer
2. Comatose

This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.

This measure reports the percentage of long-stay residents, 180 days of age and older, who were in a nursing facility for at least one day during the most recently completed influenza vaccination season (IVS), and who were assessed and appropriately given the seasonal influenza vaccine . The IVS is defined as beginning on October 1 and ends on March 31 of the following year.

This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period.

The measure reports the percentage of short stay nursing home residents or IRF or LTCH patients who were assessed and appropriately given the pneumococcal vaccine during the 12-month reporting period.

This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments of

This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument.

This measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter.