Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

NSC-12.1 - Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit.

NSC-12.2 - Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit.

NSC-12.3 - Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit.

The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

SNF HAI is a one-year outcome measure that estimates the risk-standardized rate of healthcare-associated infections (HAIs) that are acquired during SNF care and result in hospitalization.

Ratio of observed to expected major adverse events (MAE) among patients undergoing congenital cardiac catheterization, risk-adjusted using the Catheterization for Congenital Heart Disease Adjustment for Risk Method II (CHARM II).

This measure is a ratio of observed to expected rate of in-hospital mortality following non-cardiac surgery among infants <= 30 days of age, risk-adjusted.

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the measurement period.

This measure captures the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

This measure captures the proportion of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two (with the day of arrival being day 1).

This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.