Percentage of patients aged 18 years and older at the start of the measurement period with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.
Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CAUTIs by the number of predicted CAUTIs.
Number of annually observed catheter-associated urinary tract infections (CAUTI) in hospital inpatients.
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The denominator for both the SIR and the ARM is the total number of predicted CAUTI during hospitalization for patients within the unit of study (i.e., location under surveillance). The predicted number of infections for a facility is calculated based on the reported number of catheter days at the location-level using a negative binomial regression that accounts for the following risk factors:
ACHs: CDC-defined location within a facility (e.g., critical ICUs, SCAs, step-down units, etc.), bed size, medical school affiliation, and facility type
CAHs: medical school affiliation
IRFs: setting type, proportion of admissions with traumatic and non-traumatic spinal cord dysfunction, proportion of admissions with stroke
LTACHs: average length of stay, setting type, and location type.
The following are not considered indwelling catheters by NHSN definitions:
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Endorsement History:
Link to Endorsement Measure Record: National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
Impact Summary: This measure supports the Inpatient Rehabilitation Facility Quality Reporting Program by assessing health care-associated catheter-associated urinary tract infections (CAUTI) among patients in bedded inpatient rehabilitation facilities, an outcome directly associated with patient safety and quality of care.
Based on the most recent data, the total estimated number of CAUTIs across all deciles is approximately 1,400. If inpatient rehabilitation facilities with higher CAUTI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that up to about 1,400 CAUTIs could potentially be avoided, indicating a substantial opportunity for improved patient outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Inpatient Rehabilitation Facility - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “I_006_01” not marked as “Not Available” from the corresponding Inpatient_Rehabilitation_Facility-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: There is no discernible change across the 4 years. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average SIR (Standard Deviation) | 1.060 (1.089) | 0 | 0 | 0 | 0 | 0.117 | 0.688 | 1.142 | 1.706 | 2.326 | 3.562 |
| Average Raw Rate (Standard Deviation) | 0.200 (0.328) | 0 | 0 | 0 | 0 | 0.006 | 0.099 | 0.194 | 0.291 | 0.450 | 0.957 |
| Entities | 1,123 | 113 | 112 | 112 | 113 | 112 | 112 | 113 | 112 | 112 | 112 |
| Patients | 790,630 | 50,594 | 48,918 | 58,134 | 49,690 | 77,282 | 167,930 | 116,230 | 100,352 | 82,073 | 39,427 |
Table 1 Interpretation: To estimate the number of negative outcomes (CAUTIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,400. If the average performance of Decile 3 (0%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 1,400 fewer measured patients would contract CAUTIs. This translates to about one patient per entity.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs
Number of annually observed Clostridioides difficile (CDI) LabID events in hospital inpatients.
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Number of annually predicted Clostridioides difficile (CDI) LabID events in hospital inpatients.
Baby based locations such as, neonatal ICU, special care nursery and well-baby nurseries, are excluded from the denominator count. In LDRP locations, moms and babies must each be counted separately (as two patients). Any locations that predominantly house infants, including NICU, SCN, or well-baby locations (for example, nurseries, babies in LDRP) are excluded.
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Endorsement History: The measure was last endorsed in 2025 and is up for re-endorsement in 2029
Link to Endorsement Measure Record: Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio | Partnership for Quality Measurement
Impact Summary: This measure supports the Inpatient Rehabilitation Facility Quality Reporting Program by assessing facility-wide hospital-onset Clostridioides difficile infections (CDIs) among patients in inpatient rehabilitation facilities, an outcome closely tied to patient safety and infection prevention.
Based on the most recent data, the total estimated number of CDIs across all deciles is approximately 1,500. If inpatient rehabilitation facilities with higher CDI rates improved their performance to levels observed among better-performing facilities, this would result in about one less CDI per facility, indicating limited opportunity to improve patient outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Inpatient Rehabilitation Facility - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “I_015_01” not marked as “Not Available” from the corresponding Inpatient_Rehabilitation_Facility-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Figure 1 shows a decreasing trend from a median standardized infection ratio (SIR) of 0.34 in 2022 to a median SIR of 0.17 in 2024. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores (SIRs), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average SIR (Standard Deviation) | 0.320 (0.440) | 0 | 0 | 0 | 0 | 0.002 | 0.178 | 0.326 | 0.490 | 0.743 | 1.330 |
| Average Raw Rate (Standard Deviation) | 0.013 (0.020) | 0 | 0 | 0 | 0 | 0 | 0.007 | 0.013 | 0.020 | 0.030 | 0.060 |
| Entities | 1,122 | 113 | 112 | 112 | 112 | 112 | 113 | 112 | 112 | 112 | 112 |
| Patients | 10,840,927 | 793,952 | 722,084 | 664,810 | 688,265 | 716,002 | 2,010,023 | 1,862,498 | 1,374,188 | 1,203,579 | 805,526 |
Table 1 Interpretation: To estimate the number of negative outcomes (CDIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,500. If the average performance of Decile 3 (0%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated number of eligible patients with CDIs would go down by about 1,500. This translates to about one patient per entity.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This measure identifies the percentage of healthcare personnel who receive the influenza vaccination among the total number of healthcare personnel (HCP) in the facility for at least one working day between October 1 and March 31 of the following year, regardless of clinical responsibility or patient contact.
The numerator for this measure consists of HCP in the denominator population, who fall into one of the categories below. HCP should be counted as vaccinated if they receive influenza vaccine any time from when it first became available, such as August or September, through March 31 of the following year.
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The denominator for this measure consists of healthcare personnel (HCP) who are physically present in the healthcare facility for at least 1 working day between October 1 through March 31 of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:
None
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Link to Endorsement Measure Record: Influenza Vaccination Coverage Among Healthcare Personnel
Impact Summary: This measure supports the Inpatient Rehabilitation Facility Quality Reporting Program’s goal of improving the quality of inpatient rehabilitation care by assessing whether facilities implement a core infection-prevention practice, health care personnel influenza vaccination, to support safer care environments for patients receiving rehabilitation services.
Rehabilitation facility performance has steadily decreased from 2020 to 2024, indicating lower vaccination among HCP. Improving performance among lower-scoring facilities could help ensure 52,000 additional HCP receive influenza vaccinations or about 46 health care personnel per entity.
For this measure, Battelle reviewed the following publicly available datasets available at Inpatient Rehabilitation Facility - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “I_016_01” not marked as “Not Available” from the corresponding Inpatient_Rehabilitation_Facility-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Figure 1 shows a steady drop from a median value of nearly 91% in 2020 to a median value of 81% in 2024. For this measure, a higher score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the population represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain larger or smaller populations than other groups. For example, if the lowest-scoring decile includes only 5% of the total population, then smaller group size may be associated with lower performance scores.
Table 1. Importance in the most recent year of data available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 75.0 (21.0) | 29.5 | 51.6 | 63.0 | 72.2 | 78.3 | 83.3 | 87.5 | 91.2 | 95.0 | 98.7 |
| Entities | 1,118 | 112 | 112 | 112 | 112 | 111 | 112 | 112 | 112 | 112 | 111 |
| Population | 347,271 | 29,741 | 24,704 | 31,636 | 35,266 | 29,770 | 42,247 | 31,435 | 45,983 | 30,212 | 46,277 |
Table 1 Interpretation: To estimate the number of positive outcomes (influenza vaccinations for health care personnel), the population is multiplied by the average score for each decile. Right now, the total estimated number of positive outcomes across all deciles is about 270,000. If the average performance score of Decile 8 (91.2%) is considered a plausible, achievable score, and the entities in Deciles 1 through 7 improved to reach that score, about 52,000 additional positive outcomes could occur. This translates to about 46 health care personnel per entity and means that improving performance on this measure could help ensure that tens of thousands more health care workers receive influenza vaccinations, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
This measure estimates the mean risk-adjusted mean change in mobility score between admission and discharge for Inpatient Rehabilitation Facility (IRF) Medicare Part A and Medicare Advantage patients.
This measure estimates the risk-adjusted mean change in self-care score between admission and discharge for Inpatient Rehabilitation Facility (IRF) Medicare Part A and Medicare Advantage patients.
This measure estimates the percentage of IRF patients who meet or exceed an expected discharge mobility score.
This measure estimates the percentage of IRF patients who meet or exceed an expected discharge self-care score.
This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.