Quality ID#
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Measure Title and Description
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Measure Type
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High-Priority Measure
|
|
21
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Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
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.
|
Process
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No
|
|
23
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Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
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.
|
Process
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Yes
|
|
46
|
Medication Reconciliation Post-Discharge
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.
This measure is reported as three rates stratified by age group:
- Submission Criteria 1: 18-64 years of age
- Submission Criteria 2: 65 years and older
- Total Rate: All patients 18 years of age and older
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Process
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Yes
|
|
47
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Care Plan
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
|
Process
|
Yes
|
|
128
|
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
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.
Normal Parameters:
Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2
|
Process
|
No
|
|
130
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Documentation of Current Medications in the Medical Record
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.
|
Process
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Yes
|
|
226
|
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
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.
|
Process
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No
|
|
264
|
Sentinel Lymph Node Biopsy for Invasive Breast Cancer
The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.
|
Process
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No
|
|
317
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
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.
|
Process
|
No
|
|
354
|
Anastomotic Leak Intervention
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
|
Outcome
|
Yes
|
|
355
|
Unplanned Reoperation within the 30-Day Postoperative Period
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
|
Outcome
|
Yes
|
|
356
|
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
|
Outcome
|
Yes
|
|
357
|
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
|
Outcome
|
Yes
|
|
358
|
Patient-Centered Surgical Risk Assessment and Communication
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
|
Process
|
Yes
|
|
374
|
Closing the Referral Loop: Receipt of Specialist Report
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
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Process
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Yes
|
|
402
|
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12–20 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
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Process
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No
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