Elderly

This measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter.

This measure reports the percentage of long-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.

This measure reports the percentage of short-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. Short-stay nursing facility residents are identified as those who have had 100 or fewer cumulative days of nursing facility care.

The measure reports the percentage of all long-stay residents who were physically restrained daily during the 7 days prior to the target MDS 3.0 assessment (OBRA, PPS or discharge) during their episode of nursing home care ending in the target quarter (3-month period). Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use.

This measure reports the percentage of long-stay residents in a nursing home who have a urinary tract infection in the 30 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter. Long-stay nursing home residents are identified as those who have had 101 or more cumulative days of nursing home care.

Percentage of patients, aged 18 years and older, for whom percutaneous coronary intervention (PCI) is performed with comprehensive documentation for the procedure that includes, at a minimum, the following elements: priority (acute coronary syndrome, urgent, elective, emergency/salvage); presence and severity of angina symptoms; use of antianginal medical therapies within two weeks prior to the procedure, if any; presence, results, and timing of non-invasive stress test, fractional flow reserve (FFR), or intravascular ultrasound (IVUS), if performed; and significance of angiographic stenosi

0-100 measure of performance evaluation related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.