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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Vascular Access—Functional Arteriovenous Fistula (AVF) or AV Graft or Evaluation for Placement

  • Percentage of end stage renal disease (ESRD) patients aged 18 years and older receiving hemodialysis during the 12-month reporting period and on dialysis >90 days who:

    1. have a functional autogenous AVF (defined as two needles used or a single-needle device [NOT one needle used in a two-needle device]) (computed and reported separately);

    2. have a functional AV graft (computed and reported separately); or

    CBE ID
    0251

Venous Thromboembolism Patients Recieving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

  • This measure assesses the number of patients diagnosed with confirmed venous thromboembolism (VTE) who received intravenous (IV) unfractionated heparin (UFH) therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. This measure is part of a set of six prevention and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Incidence of Potentially-Preventable VTE).

    CBE ID
    0374

Venous Thromboembolism Prophylaxis

  • This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

    CBE ID
    0371

Venouse Thromboembolism Patients with Antocoagulation Overlap Therapy

  • This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of Parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy.

    CBE ID
    0373

Voluntary Turnover

  • NSC-11.1 Total number of full-time and part-time Registered Nurse (RN) and Advanced Practice Nurse (APN) voluntary uncontrolled separations occurring during the calendar month
    NSC-11.2 Total number of full-time and part-time Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) voluntary uncontrolled separations occurring during the calendar month
    NSC-11.3 Total number of full-time and part-time Unlicensed Assistive Personnel (UAP) voluntary uncontrolled separations occurring during the calendar month

    CBE ID
    0207

Waveform Capnography in Ventilated Patients: Percent of patient transport contacts with advanced airways in whom continuous waveform capnography was used.

  • This metric is designed to measure the critical care transport team's utilization of waveform capnography during critical care medical transport.  Waveform capnography has evolved as the standard for the safe placement and maintenance of advanced airways (e.g., endotracheal tubes) in adult and pediatric patients.  The metric specifically focuses on transported patients with advanced airways in whom continuous waveform capnography is appropriately used.  This metric is stratified by age into the following three categories: neonatal (defined as infants <29 days), pediatric (

    CBE ID
    4045