Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Percentage of patients who died from cancer dying in an acute care setting

Proportion of infants 22 to 29 weeks gestation treated with surfactant within 2 hours of birth among infants who were treated with surfactant.

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types:

Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period (Please reference attached document labeled NQF_Stroke_PACs_Risk_Adjustment_2.16.10.xls, tabs labeled CIP_Index PAC_Stays and CIP_PAC_Readmission). We define PACs during each time period as one of three types:

(A) PACs during the Index Stay (Hospitalization):

Proportion of patients who died from cancer not admitted to hospice

Brief Description of Measure: Percent of adult population aged 18+ years with Community Acquired Pneumonia who are followed for one-month, and have one or more potentially avoidable complication (PAC) during the episode time window. Please reference the attached document labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls, in the tab labeled PACS I-9 & I-10 for a list of code definitions of PACs relevant to pneumonia.

Percentage of patients who died from cancer with more than one hospitalization in the last 30 days of life

Percentage of children from 3.00 to 17.99 years of age seen for a pediatric well child visit who have a Pediatric Symptom Checklist (PSC) Tool administered as a component of that visit.

Percentage of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major lung resection (pneumonectomy, lobectomy, or formal segmentectomy)

This measure is an all-or-none composite of the number of patients following an ICD/CRT-D implant procedure who received prescriptions for all medications (Angiotensin-converting enzyme inhibitors (ACE-I)/ Angiotensin receptor blockers (ARB)/ Angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers) for which they are eligible at discharge and those patients with procedures that fulfill class I, IIa, or IIb guideline indications.