Facility

Documents the extent to which a provider uses certified/qualified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data into the EHR as discrete searchable data elements.

Primary Measure - Most and Moderately Effective Contraceptive Provision or Use: Percentage of patients ages 15-44 and assigned female at birth who received a most or moderately effective contraceptive, or were documented to use a most or moderately effective contraceptive method in the measurement period. The primary measure captures new provision as well as current use of most and moderately effective contraceptive methods to accurately capture contraceptive utilization even if provided in a different calendar year or a different health care site.

Primary Measure - Most and Moderately Effective Contraceptive Provision or Use: Percentage of patients ages 15-44 assigned female at birth with a live birth delivery who received a most or moderately effective contraceptive, or were documented to use a most or moderately effective contraceptive method, in the postpartum period. The primary measure captures new provision as well as current use of most and moderately effective contraceptive methods to accurately capture postpartum contraceptive utilization even if provided in a different calendar year or a different health care site.

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.

Percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first “operating room” procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication. 

This measure calculates the percentage of thorax computed tomography (CT) studies that are performed without and with contrast, out of all thorax CT studies performed (those without contrast, those with contrast, and those with both) at each facility. The measure is calculated based on a one-year window of Medicare fee-for-service claims data. The measure has been publicly reported annually by the measure steward, the Centers for Medicare & Medicaid Services (CMS), since 2010, as a component of its Hospital Outpatient Quality Reporting (HOQR) Program.