Populations at Risk

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:
a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:
a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
b. Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention

Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months.

Percentage of adult dialysis patients with a 3-month rolling average of total uncorrected calcium (serum or plasma) greater than 10.2 mg/dL (hypercalcemia)

Percentage of SUI surgeries for which cystoscopy was used during the surgical procedure to reduce complications

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients. Excludes cases with principal diagnosis of retained surgical item or unretrieved device fragment and cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

Patients age 50 or over with a fragility fracture who have either a dual-energy X-Ray absorptiometry (DXA) scan ordered or performed, or a prescription for FDA-approved pharmacotherapy for osteoporosis, or who are seen by or linked to a fracture liaison service prior to discharge from inpatient status,. If DXA is not available and documented as such, then any other specified fracture risk assessment method may be ordered or performed.

This measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option. This proposal is to focus on patients who have undergone any one of 7 common, important surgical procedures: total replacement of the knee or hip, lower back surgery for spinal stenosis of herniated disc, radical prostatectomy for prostate cancer, mastectomy for early stage breast cancer or percutaneous coronary intervention (PCI) for stable angina.

NSC-12.1 - Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit.

NSC-12.2 - Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit.

NSC-12.3 - Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit.

The standardized hospitalization ratio is defined to be the ratio of the number of hospital admissions that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of hospitalizations that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.