Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use.

This measure reports the percentage of long-stay residents in a nursing home who have a urinary tract infection in the 30 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter. Long-stay nursing home residents are identified as those who have had 101 or more cumulative days of nursing home care.

Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life

Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life

Risk adjusted rate of intra and post procedure bleeding for all patients age 18 and over undergoing PCI.

Admissions for any-listed diagnosis of perforations or abscesses of the appendix per 1,000 admissions with any-listed appendicitis, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

[NOTE: The software provides the rate per hospital admission. However, common practice reports the measure as per 1,000 admissions. The user must multiply the rate obtained from the software by 1,000 to report cases per 1,000 admissions.]

0-100 measure of performance evaluation related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.