Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.
Category: Quality Measures
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization.
Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy
If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the performance period.
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart for whom a functional status assessment was performed at least once during the performance period.
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan during the performance period.
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.
Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies within two days of the date of the identified deficiencies.
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.
Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.