|
Quality Id |
Measure Name |
High Priority |
Measure Type |
Measure Description |
|
021 |
Perioperative Care: Selection of
Prophylactic Antibiotic – First OR Second Generation Cephalosporin |
No |
Process |
Percentage
of surgical patients aged 18 years and older undergoing procedures with the
indications for a first OR second generation cephalosporin prophylactic
antibiotic, who had an order for a first OR second generation cephalosporin
for antimicrobial prophylaxis |
|
023 |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL
Patients) |
Yes |
Process |
Percentage
of surgical patients aged 18 years and older undergoing procedures for which
venous thromboembolism (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 |
|
046 |
Medication
Reconciliation Post-Discharge |
Yes |
Process |
The
percentage of discharges from any inpatient facility (e.g. hospital, skilled
nursing facility, or rehabilitation facility) for patients 18 years and older
of age seen within 30 days following discharge in the office by the
physician, prescribing practitioner, registered nurse, or clinical pharmacist
providing on-going care for whom the discharge medication list was reconciled
with the current medication list in the outpatient medical record. |
|
047 |
Care
Plan |
Yes |
Process |
Percentage
of patients aged 65 years and older who have an advance care plan or
surrogate decision maker documented in the medical record that an advance
care plan was discussed but the patient did not wish or was not able to name
a surrogate decision maker or provide an advance care plan |
|
128 |
Preventive
Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
No |
Process |
Percentage
of patients aged 18 years and older with a BMI documented during the current
encounter or during the previous twelve months AND with a BMI outside of
normal parameters, a follow-up plan is documented during the encounter or
during the previous twelve months of the current encounter |
|
130 |
Documentation
of Current Medications in the Medical Record |
Yes |
Process |
Percentage
of visits for patients aged 18 years and older for which the eligible
professional or eligible clinician attests to documenting a list of current
medications using all immediate resources available on the date of the
encounter. This list must include ALL known prescriptions, over-the-counters,
herbals, and vitamin/mineral/dietary (nutritional) supplements AND must
contain the medications’ name, dosage, frequency and route of administration |
|
226 |
Preventive
Care and Screening: Tobacco Use: Screening and Cessation Intervention |
No |
Process |
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 |
|
317 |
Preventive
Care and Screening: Screening for High Blood Pressure and Follow-Up
Documented |
No |
Process |
Percentage
of patients aged 18 years and older seen during the submitting period who
were screened for high blood pressure AND a recommended follow-up plan is
documented based on the current blood pressure (BP) reading as indicated |
|
355 |
Unplanned
Reoperation within the 30 Day Postoperative Period |
Yes |
Outcome |
Percentage
of patients aged 18 years and older who had any unplanned reoperation within
the 30 day postoperative period |
|
356 |
Unplanned
Hospital Readmission within 30 Days of Principal Procedure |
Yes |
Outcome |
Percentage
of patients aged 18 years and older who had an unplanned hospital readmission
within 30 days of principal procedure |
|
357 |
Surgical
Site Infection (SSI) |
Yes |
Outcome |
Percentage
of patients aged 18 years and older who had a surgical site infection (SSI) |
|
358 |
Patient-Centered
Surgical Risk Assessment and Communication |
Yes |
Process |
Percentage
of patients who underwent a non-emergency surgery who had their personalized
risks of postoperative complications assessed by their surgical team prior to
surgery using a clinical data-based, patient-specific risk calculator and who
received personal discussion of those risks with the surgeon |
|
374 |
Closing
the Referral Loop: Receipt of Specialist Report |
Yes |
Process |
Percentage
of patients with referrals, regardless of age, for which the referring
provider receives a report from the provider to whom the patient was referred |
|
402 |
Tobacco
Use and Help with Quitting Among Adolescents |
No |
Process |
The
percentage of adolescents 12 to 20 years of age with a primary care visit
during the measurement year for whom tobacco use status was documented and
received help with quitting if identified as a tobacco user |