|
Quality Id |
Measure Name |
High Priority |
Measure Type |
Measure Description |
|
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 |
|
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 |
|
048 |
Urinary
Incontinence: Assessment of Presence or Absence of Urinary Incontinence in
Women Aged 65 Years and Older |
No |
Process |
Percentage
of female patients aged 65 years and older who were assessed for the presence
or absence of urinary incontinence within 12 months |
|
050 |
Urinary
Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years
and Older |
Yes |
Process |
Percentage
of female patients aged 65 years and older with a diagnosis of urinary
incontinence with a documented plan of care for urinary incontinence at least
once within 12 months |
|
102 |
Prostate
Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate
Cancer Patients |
No |
Process |
Percentage
of patients, regardless of age, with a diagnosis of prostate cancer at low
(or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the
prostate, OR radical prostatectomy, OR cryotherapy
who did not have a bone scan performed at any time since diagnosis of
prostate cancer |
|
104 |
Prostate
Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High
Risk Prostate Cancer |
No |
Process |
Percentage
of patients, regardless of age, with a diagnosis of prostate cancer at high
or very high risk of recurrence receiving external beam radiotherapy to the
prostate who were prescribed androgen deprivation therapy in combination with
external beam radiotherapy to the prostate |
|
119 |
Diabetes:
Medical Attention for Nephropathy |
No |
Process |
The
percentage of patients 18-75 years of age with diabetes who had a nephropathy
screening test or evidence of nephropathy during the measurement period |
|
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 |
|
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 |
|
265 |
Biopsy
Follow-Up |
Yes |
Process |
Percentage
of new patients whose biopsy results have been reviewed and communicated to
the primary care/referring physician and patient by the performing physician |
|
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 |
|
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 |
|
428 |
Pelvic
Organ Prolapse: Preoperative Assessment of Occult
Stress Urinary Incontinence |
No |
Process |
Percentage
of patients undergoing appropriate preoperative evaluation of stress urinary
incontinence prior to pelvic organ prolapse surgery
per ACOG/AUGS/AUA guidelines |
|
429 |
Pelvic
Organ Prolapse: Preoperative Screening for Uterine
Malignancy |
Yes |
Process |
Percentage
of patients who are screened for uterine malignancy prior to vaginal closure
or obliterative surgery for pelvic organ prolapse |
|
431 |
Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling |
No |
Process |
Percentage
of patients aged 18 years and older who were screened for unhealthy alcohol
use using a systematic screening method at least once within the last 24
months AND who received brief counseling if identified as an unhealthy
alcohol user |
|
432 |
Proportion
of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing any surgery to repair pelvic organ prolapse
who sustains an injury to the bladder recognized either during or within 1
month after surgery |
|
433 |
Proportion
of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing surgical repair of pelvic organ prolapse
that is complicated by a bowel injury at the time of index surgery that is
recognized intraoperatively or within 1 month after
surgery |
|
434 |
Proportion
of Patients Sustaining a Ureter Injury at the Time
of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing pelvic organ prolapse
repairs who sustain an injury to the ureter
recognized either during or within 1 month after surgery |