Quality Definitions and Methodology

Collection Periods

Measure Collection Period
From To
Hospital Return Days
EDAC-30-HF. Heart Failure07/01/201806/30/2021
EDAC-30-PN. Pneumonia07/01/201806/30/2021
EDAC_30_AMI. Heart Attack07/01/201806/30/2021
Visit Rates Following OP Procedure
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy07/01/202012/31/2020
OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy07/01/202012/31/2020
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery07/01/202012/31/2020
Readmission Reduction
READM-30-AMI-HRRP. Heart Attack07/01/201712/01/2019
READM-30-HF-HRRP. Heart Failure07/01/201712/01/2019
READM-30-PN-HRRP. Pneumonia07/01/201712/01/2019
READM-30-COPD-HRRP. COPD07/01/201712/01/2019
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery07/01/201712/01/2019
Timely Heart Attack Care
OP-2. Fibrinolytic Therapy received within 30 minutes10/01/202009/30/2021
OP-3b. Median Time to transfer patients for Acute Coronary Intervention10/01/202009/30/2021
Timely Emergency Department Care
OP-18b. Average time patients spent in the emergency department before being sent home10/01/202009/30/2021
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients.10/01/202009/30/2021
OP-22. Percentage of patients who left the emergency department before being seen01/01/202012/31/2020
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival10/01/202009/30/2021
Preventive Care
IMM-3. Healthcare workers given influenza vaccination10/01/202003/31/2021
Pregnancy and Delivery Care
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary10/01/202009/30/2021
Survey of Patient Hospital Experiences
HCAHPS. Patient Survey Results10/01/202009/30/2021
30-Day Risk Adjusted Mortality Rates
MORT-30-CABG. CABG07/01/201806/30/2021
MORT-AMI. Heart Attack07/01/201806/30/2021
MORT-HF. Heart Failure07/01/201806/30/2021
MORT-PN. Pneumonia07/01/201806/30/2021
MORT-30-COPD. COPD07/01/201806/30/2021
MORT-30-STK. Stroke07/01/201806/30/2021
30-Day Risk Adjusted Readmission Rates
OP-32. Colonoscopy01/01/201812/31/2020
READM-30-CABG. CABG07/01/201806/30/2021
READM-AMI. Heart Attack07/01/201806/30/2021
READM-HF. Heart Failure07/01/201806/30/2021
READM-PN. Pneumonia07/01/201806/30/2021
READM-30-COPD. COPD07/01/201806/30/2021
READM-30-HIP-KNEE. Hip/Knee Surgery07/01/201806/30/2021
READM-30-HOSPWIDE. Hospital-wide07/01/202006/30/2021
Surgical Complications
Complications for Hip/Knee Replacements04/01/201803/31/2021
PSI-3. Pressure sores07/01/201906/30/2021
PSI-4. Death from serious treatable complications after surgery07/01/201906/30/2021
PSI-6. Collapsed lung due to medical treatment07/01/201906/30/2021
PSI-8. Broken hip from a fall after surgery07/01/201906/30/2021
PSI-9. Postoperative Hemorrhage or Hematoma Rate07/01/201906/30/2021
PSI-10. Postoperative Acute Kidney Injury Rate07/01/201906/30/2021
PSI-11. Postoperative Respiratory Failure Rate07/01/201906/30/2021
PSI-12. Serious blood clots after surgery07/01/201906/30/2021
PSI-13. Blood stream infection after surgery07/01/201906/30/2021
PSI-14. A wound that splits open after surgery07/01/201906/30/2021
PSI-15. Accidental cuts and tears from medical treatment07/01/201906/30/2021
PSI-90. Serious Complications07/01/201906/30/2021
Healthcare Associated Infections
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)10/01/202009/30/2021
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)10/01/202009/30/2021
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)10/01/202009/30/2021
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy)10/01/202009/30/2021
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections10/01/202009/30/2021
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)10/01/202009/30/2021
Use of Medical Imaging
OP-8. MRI Lumbar Spine for Low Back Pain07/01/202006/30/2021
OP-10. Abdomen CT - Use of Contrast Material07/01/201912/31/2019
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery07/01/202006/30/2021
OP-39. Breast Cancer Screening Recall Rates07/01/202006/30/2021
Medicare Spending Per Beneficiary
MSPB. Medicare Spending per Beneficiary07/01/202012/31/2020
Cataract Surgery Outcome
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery01/01/202012/31/2020
Colonoscopy care
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients01/01/202012/31/2020
HBIPS-2. Hours of physical-restraint use01/01/202012/31/2020
HBIPS-3. Hours of seclusion01/01/202012/31/2020
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification01/01/202012/31/2020
READM-30-IPF. Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility07/01/201812/31/2019
SMD. Screening for metabolic disorders01/01/202012/31/2020
SUB-2. Alcohol use brief intervention provided or offered01/01/202012/31/2020
SUB-2A. Alcohol use brief intervention received01/01/202012/31/2020
SUB-3. Alcohol and other drug use disorder treatment provided or offered at discharge01/01/202012/31/2020
SUB-3A. Alcohol and other drug use disorder treatment receieved01/01/202012/31/2020
TOB-2. Tobacco use treatment provided or offered01/01/202012/31/2020
TOB-2A. Tobacco use treatment received01/01/202012/31/2020
TOB-3. Tobacco use treatment provided or offered at discharge01/01/202012/31/2020
TOB-3A. Tobacco use treatment received at discharge01/01/202012/31/2020
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days07/01/201912/31/2019
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days07/01/201912/31/2019