Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

The ratio of actual deaths over predicted deaths for PICU patients.

The total number of patients requiring unscheduled readmission to the ICU within 24 hours of discharge or transfer.

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:

1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission

*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

Percent of pneumonia patients, age 18 years or older, transferred or admitted to the ICU within 24 hours of hospital arrival who had blood cultures performed within 24 hours prior to or 24 hours after arrival at the hospital.

Inpatients age 65 years and older and 5-64 years of age who have a high risk condition who are screened for Pneumococcal Vaccine status and vaccinated prior to discharge if indicated.

Percentage of home health episodes of care during which patients were determined to have ever received Pneumococcal Polysaccharide Vaccine (PPV).

Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.

PointRight OnPoint-30 is an all-cause, risk adjusted rehospitalization measure. It provides the rate at which all patients (regardless of payer status or diagnosis) who enter skilled nursing facilities (SNFs) from acute hospitals and are subsequently rehospitalized during their SNF stay, within 30 days from their admission to the SNF.

The PointRight Pro Long Stay Hospitalization Measure is an MDS-based, risk-adjusted measure of the rate of hospitalization of long-stay patients (also known as “residents”) of skilled nursing facilities (SNFs) averaged across the year, weighted by the number of stays in each quarter.

Percentage of persons > 13 years of age with diagnosed HIV infection who are virally suppressed in the measurement year.