|
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 |
|
024 |
Communication
with the Physician or Other Clinician Managing On-going Care Post-Fracture
for Men and Women Aged 50 Years and Older |
Yes |
Process |
Percentage
of patients aged 50 years and older treated for a fracture with documentation
of communication, between the physician treating the fracture and the
physician or other clinician managing the patient’s on-going care, that a
fracture occurred and that the patient was or should be considered for
osteoporosis treatment or testing. This measure is reported by the physician
who treats the fracture and who therefore is held accountable for the
communication |
|
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 |
|
109 |
Osteoarthritis
(OA): Function and Pain Assessment |
Yes |
Process |
Percentage
of patient visits for patients aged 21 years and older with a diagnosis of
osteoarthritis (OA) with assessment for function and pain |
|
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 |
|
131 |
Pain
Assessment and Follow-Up |
Yes |
Process |
Percentage
of visits for patients aged 18 years and older with documentation of a pain
assessment using a standardized tool(s) on each visit AND documentation of a
follow-up plan when pain is present |
|
134 |
Preventive
Care and Screening: Screening for Depression and Follow-Up Plan |
No |
Process |
Percentage
of patients aged 12 years and older screened for depression on the date of
the encounter using an age appropriate standardized depression screening tool
AND if positive, a follow-up plan is documented on the date of the positive
screen |
|
154 |
Falls:
Risk Assessment |
Yes |
Process |
Percentage
of patients aged 65 years and older with a history of falls that had a risk
assessment for falls completed within 12 months |
|
155 |
Falls:
Plan of Care |
Yes |
Process |
Percentage
of patients aged 65 years and older with a history of falls that had a plan
of care for falls documented within 12 months |
|
178 |
Rheumatoid
Arthritis (RA): Functional Status Assessment |
No |
Process |
Percentage
of patients aged 18 years and older with a diagnosis of rheumatoid arthritis
(RA) for whom a functional status assessment was performed at least once
within 12 months |
|
179 |
Rheumatoid
Arthritis (RA): Assessment and Classification of Disease Prognosis |
No |
Process |
Percentage
of patients aged 18 years and older with a diagnosis of rheumatoid arthritis
(RA) who have an assessment and classification of disease prognosis at least
once within 12 months |
|
180 |
Rheumatoid
Arthritis (RA): Glucocorticoid Management |
No |
Process |
Percentage
of patients aged 18 years and older with a diagnosis of rheumatoid arthritis
(RA) who have been assessed for glucocorticoid use
and, for those on prolonged doses of prednisone ≥ 10 mg daily (or
equivalent) with improvement or no change in disease activity, documentation
of glucocorticoid management plan within 12 months |
|
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 |
|
350 |
Total
Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical)
Therapy |
Yes |
Process |
Percentage
of patients regardless of age undergoing a total knee replacement with
documented shared decision-making with discussion of conservative
(non-surgical) therapy (e.g. nonsteroidal
anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise,
injections) prior to the procedure |
|
351 |
Total
Knee Replacement: Venous Thromboembolic and
Cardiovascular Risk Evaluation |
Yes |
Process |
Percentage
of patients regardless of age undergoing a total knee replacement who are
evaluated for the presence or absence of venous thromboembolic
and cardiovascular risk factors within 30 days prior to the procedure (e.g.
history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial
Infarction (MI), Arrhythmia and Stroke) |
|
352 |
Total
Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet |
Yes |
Process |
Percentage
of patients regardless of age undergoing a total knee replacement who had the
prophylactic antibiotic completely infused prior to the inflation of the proximal
tourniquet |
|
353 |
Total
Knee Replacement: Identification of Implanted Prosthesis in Operative Report |
Yes |
Process |
Percentage
of patients regardless of age undergoing a total knee replacement whose
operative report identifies the prosthetic implant specifications including
the prosthetic implant manufacturer, the brand name of the prosthetic implant
and the size of each prosthetic implant |
|
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 |
|
408 |
Opioid Therapy Follow-up Evaluation |
No |
Process |
All
patients 18 and older prescribed opiates for longer than six weeks duration
who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |