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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Bipolar Disorder: Level-of-function evaluation

  • Percentage of patients treated for bipolar disorder with evidence of level-of-function evaluation at the time of the initial assessment and again within 12 weeks of initiating treatment

    CBE ID
    0112

Bloodstream Infection in Hemodialysis Outpatients

  • Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

    CBE ID
    1460

Body Mass Index Screening and Follow-Up for People with Serious Mental Illness

  • The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).

    Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS and used in the Physician Quality Reporting System.

    CBE ID
    2601

Breast Cancer Screening

  • Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

    CBE ID
    2372

Breast Cancer Screening

  • Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer

    CBE ID
    0031

CAC-1: Relievers for Inpatient Asthma

  • Use of relievers in pediatric patients, age 2 years through 17 years, admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-2: Systemic Corticosteroids for Inpatient Asthma, and CAC-03: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver) that are used in The Joint Commission’s accreditation process.

    CBE ID
    0143

CAC-2 Systemic corticosteroids for Inpatient Asthma

  • Use of systemic corticosteroids in pediatric asthma patients (age 2 through 17 years) admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, CAC-3: Home Management Plan of Care (HMPC) Document Given to Parent/Caregiver) that are used in The Joint Commission’s accreditation process.

    CBE ID
    0144

CAC-3: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver

  • This measure assesses the proportion of pediatric asthma patients discharged from an inpatient hospital stay with a Home Management Plan of Care (HMPC) document in place. This measure is one of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, and CAC-2: Systemic Corticosteroids for Inpatient Asthma) that are used in The Joint Commission’s accreditation process.

    CBE ID
    0338