Elderly

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.

The proportion of in-center hemodialysis, home hemodialysis, and peritoneal dialysis patients who have documentation of receiving a new post-dialysis weight prescription from a nephrologist in the reporting month, irrespective of whether or not a change in post dialysis weight prescription was made.

Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivilant such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time.

Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time