Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

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.

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.

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

Percentage of intensive care patients with central lines for whom all
elements of the central line bundle are documented and in place.
The central line bundle elements include:
•Hand hygiene
•Maximal barrier precautions upon insertion
•Chlorhexidine skin antisepsis
•Optimal catheter site selection, with avoidance of the femoral vein for central venous access in patients 18 years and older
•Daily review of line necessity with prompt removal of unnecessary lines

The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
-Women 21–64 years of age who had cervical cytology performed within the last 3 years.
-Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
-Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years.

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care.

The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:


Communication with Parent
1. Communication between you and your child’s nurses (3 items)

Age and gender specific calculation of BMI based on parent reported height and weight of child. The measure uses CDC BMI-for-age guidelines in attributing overweight status (85th percentile up to 94th percentile) and obesity status (95th percentile and above).

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine.

Measures how many times per week child 6-17 years exercises vigorously (based on AAP and CDC recommendations)