Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay.

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge.

Rate 1 (SAC): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler during the same 90-day period.

Rate 2 (ACT): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of short-acting beta2 agonist inhalers over a 90-day period and who did not receive controller therapy during the same 90-day period.

The measure is a PRE-PM, which calculates the percentage of contraceptive care patients who give a “top box” score for their experience of contraceptive counseling. The measure is a four-question survey which asks patients about key components of patient-centered counseling, including respect and adequate information. A “top box” score is defined as a response which gives the highest score for each of the four questions. Respondents give answers evaluating the quality of contraceptive care they received in the past six months.

The measure calculates the percentage of family or designated responsible party for long stay residents (i.e., residents living in the facility for 100 days or more), who are satisfied. This consumer reported outcome measure is based on the CoreQ: Long-Stay Family questionnaire that has three items.  

The measure calculates the percentage of long-stay residents, those living in the skilled nursing facility for 100 days or more, who are satisfied. This patient reported outcome measure is based on the CoreQ: Long-Stay Resident questionnaire that is a three-item questionnaire.  

The measure calculates the percentage of individuals discharged in a six-month time period from a SNF, within 100 days of admission, who are satisfied. This patient reported outcome measure is based on the CoreQ: Short Stay Discharge questionnaire that utilizes four items.

Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or  have had female sterilization from the denominator.

This facility-level measure estimates an all-cause, unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease.

The performance period for the measure is 24 months.

Percent of acute ischemic stroke patients receiving intravenous alteplase therapy during the hospital stay who have a time from hospital arrival to initiation of thrombolytic therapy (door-to-needle time) of 60 minutes or less