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.
Percentage of patients aged 50 years to 75 years receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery
This measure assesses facility level compliance with administration of the CollaboRATE Shared Decision-Making tool to patients undergoing outpatient or ambulatory surgery. To be compliant, facilities must offer 95% of patients the option to complete the CollaboRATE survey within 1 week of the shared decision making conversation.
CollaboRATE has been administered as a paper handout, via mail, electronic mail, computer or web interface, voice recorded telephone interviews, SMS text messages, and through MyChart EHR integration.
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
Percentage of ASC admissions experiencing a fall in the ASC.
This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.
All cataract surgery patients who had an unplanned anterior vitrectomy.
N/A
N/A
All cataract surgery patients.
None.
N/A
N/A
Impact Summary: This measure aligns with the Ambulatory Surgical Center Quality Reporting (ASCQR) objectives by enabling both facilities and consumers to evaluate and compare the quality of care for cataract surgery provided in the ambulatory surgical center (ASC) setting and ensuring that care processes support the best possible patient outcomes. Specifically, the measure assesses the percentage of cataract surgery patients who experience an unplanned anterior vitrectomy (a lower score indicates better quality of care).
Figure 1 shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. Table 1 shows that if all entities performed at least at the average, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, a small increase that may potentially leading to better health outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:
Battelle analyzed all numeric values in column “ASC-14 Rating*” from the corresponding ASC_Facility.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: This figure shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores across deciles for the most recent year of data available.
Table 1. Importance (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) | 0.47 (3.52) | 0 | 0.01 | 0.08 | 0.13 | 0.19 | 0.26 | 0.34 | 0.45 | 0.63 | 2.62 |
| Entities | 1,640 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 |
Table 1 Interpretation: Nearly 20% of the entities have a score at or near 0%, and about 80% have a score less than 0.5%. If the average performance of Decile 3 (0.8%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, 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.