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Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

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Valid for Initial Endorsement
Valid for Maintenance

CAHPS Clinician & Group Surveys (CG-CAHPS) Version 3.0 -Adult, Child

The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey 3.0 (CG-CAHPS) is a standardized survey instrument that asks patients to report on their experiences with primary or specialty care received from providers and their staff in ambulatory care settings over the preceding 6 months.

CBE ID
0005

CAHPS® Hospice Survey, Version 9.0

The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the care experiences of hospice patients and their primary caregivers. Respondents to the survey are the primary informal caregivers of patients who died under hospice care. These are typically family members but can be friends. The hospice identifies the primary informal caregiver from their administrative records.

CBE ID
2651

Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery

This measure calculates the percentage of stress echocardiography, single photon emission computed tomography myocardial perfusion imaging (SPECT MPI), stress magnetic resonance imaging (MRI), or computed coronary tomography angiography (CCTA) performed at each facility in the 30 days prior to an ambulatory non-cardiac, low-risk surgery performed at any location. The measure is calculated based on a one-year window of Medicare claims data.

CBE ID
0669

Cardiac Rehabilitation Patient Referral From an Inpatient Setting

Percentage of patients aged 18 years and older admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.

CBE ID
0642

Cardiac Rehabilitation Patient Referral From an Outpatient Setting

Percentage of patients evaluated in an outpatient setting who in the previous 12 months have experienced an acute myocardial infarction or chronic stable angina or who have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation, who have not already participated in an early outpatient cardiac rehabilitation/secondary prevention program for the qualifying event, and who are referred to an outpatient cardiac rehabilitation/secondary prevention program.

CBE ID
0643

CARE - Consumer Assessments and Reports of End of Life

The CARE survey is mortality follow back survey that is administered to the bereaved family members of adult persons (age 18 and older) who died of a chronic progressive illness receiving services for at least 48 hours from a home health agency, nursing homes, hospice, or acute care hospital. The survey measures perceptions of the quality of care either in terms of unmet needs, family reports of concerns with the quality of care, and overall rating of the quality of care.

CBE ID
1632

Care for Older Adults (COA) – Medication Review

Percentage of adults 65 years and older who had a medication review during the measurement year. A medication review is a review of all a patient’s medications, including prescription medications, over-the-counter (OTC) medications and herbal or supplemental therapies by a prescribing practitioner or clinical pharmacist.

CBE ID
0553

CARE: Improvement in Mobility

The measure calculates a skilled nursing facility’s (SNFs) average change in mobility for patients admitted from a hospital who are receiving therapy. The measure calculates the average change in mobility score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the mobility subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment.

CBE ID
2612

CARE: Improvement in Self Care

The measure calculates a skilled nursing facility’s (SNFs) average change in self care for patients admitted from a hospital who are receiving therapy. The measure calculates the average change in self care score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the self care subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment.

CBE ID
2613