|
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 |
|
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 |
|
236 |
Controlling
High Blood Pressure |
Yes |
Intermediate
Outcome |
Percentage
of patients 18-85 years of age who had a diagnosis of hypertension and whose
blood pressure was adequately controlled (<140/90mmHg) during the
measurement period |
|
257 |
Statin Therapy at Discharge after Lower Extremity
Bypass (LEB) |
No |
Process |
Percentage
of patients aged 18 years and older undergoing infra-inguinal lower extremity
bypass who are prescribed a statin medication at
discharge |
|
258 |
Rate
of Open Repair of Small or Moderate Non-Ruptured Infrarenal
Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to
Home by Post-Operative Day #7) |
Yes |
Outcome |
Percent
of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not
experience a major complication (discharge to home no later than
post-operative day #7) |
|
259 |
Rate
of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major
Complications (Discharged to Home by Post Operative Day #2) |
Yes |
Outcome |
Percent
of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not
experience a major complication (discharged to home no later than
post-operative day #2) |
|
260 |
Rate
of Carotid Endarterectomy (CEA) for Asymptomatic
Patients, without Major Complications (Discharged to Home by Post-Operative
Day #2) |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CEA who are discharged to home no later
than post-operative day #2 |
|
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 |
|
344 |
Rate
of Carotid Artery Stenting (CAS) for Asymptomatic
Patients, Without Major Complications (Discharged to Home by Post-Operative
Day #2) |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CAS who are discharged to home no later
than post-operative day #2 |
|
345 |
Rate
of Asymptomatic Patients Undergoing Carotid Artery Stenting
(CAS) Who Are Stroke Free or Discharged Alive |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CAS who are stroke free while in the
hospital or discharged alive following surgery |
|
346 |
Rate
of Asymptomatic Patients Undergoing Carotid Endarterectomy
(CEA) Who Are Stroke Free or Discharged Alive |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CEA who are stroke free or discharged
alive following surgery |
|
347 |
Rate
of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are
Discharged Alive |
Yes |
Outcome |
Percent
of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are
discharged alive |
|
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 |
|
417 |
Rate
of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where
Patients Are Discharged Alive |
Yes |
Outcome |
Percentage
of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are
discharged alive |
|
420 |
Varicose
Vein Treatment with Saphenous Ablation: Outcome
Survey |
No |
Outcome |
Percentage
of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary
treatment) that report an improvement on a disease specific patient reported
outcome survey instrument after treatment |
|
423 |
Perioperative Anti-platelet Therapy
for Patients Undergoing Carotid Endarterectomy |
No |
Process |
Percentage
of patients undergoing carotid endarterectomy (CEA)
who are taking an anti-platelet agent within 48 hours prior to surgery and
are prescribed this medication at hospital discharge following surgery |
|
441 |
Ischemic
Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) |
Yes |
Intermediate
Outcome |
The
IVD All-or-None Measure is one outcome measure (optimal control). The measure
contains four goals. All four goals within a measure must be reached in order
to meet that measure. The numerator for the all-or-none measure should be
collected from the organization's total IVD denominator. All-or-None Outcome
Measure (Optimal Control) - Using the IVD denominator optimal results
include: |