| Hospital Return Days |
| EDAC-30-HF. Heart Failure | 07/01/2017 | 12/01/2019 |
| EDAC-30-PN. Pneumonia | 07/01/2017 | 12/01/2019 |
| EDAC_30_AMI. Heart Attack | 07/01/2017 | 12/01/2019 |
| Visit Rates Following OP Procedure |
| OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy | 07/01/2020 | 12/31/2020 |
| OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 07/01/2020 | 12/31/2020 |
| OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery | 07/01/2020 | 12/31/2020 |
| Readmission Reduction |
| READM-30-AMI-HRRP. Heart Attack | 07/01/2017 | 12/01/2019 |
| READM-30-HF-HRRP. Heart Failure | 07/01/2017 | 12/01/2019 |
| READM-30-PN-HRRP. Pneumonia | 07/01/2017 | 12/01/2019 |
| READM-30-COPD-HRRP. COPD | 07/01/2017 | 12/01/2019 |
| READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery | 07/01/2017 | 12/01/2019 |
| Timely Heart Attack Care |
| OP-2. Fibrinolytic Therapy received within 30 minutes | 07/01/2020 | 03/31/2021 |
| OP-3b. Median Time to transfer patients for Acute Coronary Intervention | 07/01/2020 | 03/31/2021 |
| Timely Emergency Department Care |
| OP-18b. Average time patients spent in the emergency department before being sent home | 07/01/2020 | 03/31/2021 |
| OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. | 07/01/2020 | 03/31/2021 |
| OP-22. Percentage of patients who left the emergency department before being seen | 01/01/2020 | 12/31/2020 |
| OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival | 07/01/2020 | 03/31/2021 |
| Preventive Care |
| IMM-3. Healthcare workers given influenza vaccination | 10/01/2020 | 03/31/2021 |
| Pregnancy and Delivery Care |
| PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary | 07/01/2020 | 03/31/2021 |
| Survey of Patient Hospital Experiences |
| HCAHPS. Patient Survey Results | 07/01/2020 | 03/31/2021 |
| 30-Day Risk Adjusted Mortality Rates |
| MORT-30-CABG. CABG | 07/01/2017 | 12/01/2019 |
| MORT-AMI. Heart Attack | 07/01/2017 | 12/01/2019 |
| MORT-HF. Heart Failure | 07/01/2017 | 12/01/2019 |
| MORT-PN. Pneumonia | 07/01/2017 | 12/01/2019 |
| MORT-30-COPD. COPD | 07/01/2017 | 12/01/2019 |
| MORT-30-STK. Stroke | 07/01/2017 | 12/01/2019 |
| 30-Day Risk Adjusted Readmission Rates |
| OP-32. Colonoscopy | 01/01/2018 | 12/31/2020 |
| READM-30-CABG. CABG | 07/01/2017 | 12/01/2019 |
| READM-AMI. Heart Attack | 07/01/2017 | 12/01/2019 |
| READM-HF. Heart Failure | 07/01/2017 | 12/01/2019 |
| READM-PN. Pneumonia | 07/01/2017 | 12/01/2019 |
| READM-30-COPD. COPD | 07/01/2017 | 12/01/2019 |
| READM-30-HIP-KNEE. Hip/Knee Surgery | 07/01/2017 | 12/01/2019 |
| READM-30-HOSPWIDE. Hospital-wide | 07/01/2019 | 12/01/2019 |
| Surgical Complications |
| Complications for Hip/Knee Replacements | 04/01/2017 | 10/02/2019 |
| PSI-3. Pressure sores | 07/01/2018 | 12/31/2019 |
| PSI-4. Death from serious treatable complications after surgery | 07/01/2018 | 12/31/2019 |
| PSI-6. Collapsed lung due to medical treatment | 07/01/2018 | 12/31/2019 |
| PSI-8. Broken hip from a fall after surgery | 07/01/2018 | 12/31/2019 |
| PSI-9. Postoperative Hemorrhage or Hematoma Rate | 07/01/2018 | 12/31/2019 |
| PSI-10. Postoperative Acute Kidney Injury Rate | 07/01/2018 | 12/31/2019 |
| PSI-11. Postoperative Respiratory Failure Rate | 07/01/2018 | 12/31/2019 |
| PSI-12. Serious blood clots after surgery | 07/01/2018 | 12/31/2019 |
| PSI-13. Blood stream infection after surgery | 07/01/2018 | 12/31/2019 |
| PSI-14. A wound that splits open after surgery | 07/01/2018 | 12/31/2019 |
| PSI-15. Accidental cuts and tears from medical treatment | 07/01/2018 | 12/31/2019 |
| PSI-90. Serious Complications | 07/01/2018 | 12/31/2019 |
| Healthcare Associated Infections |
| HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) | 10/01/2019 | 03/31/2021 |
| HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) | 10/01/2019 | 03/31/2021 |
| HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) | 10/01/2019 | 03/31/2021 |
| HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) | 10/01/2019 | 03/31/2021 |
| HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections | 10/01/2019 | 03/31/2021 |
| HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) | 10/01/2019 | 03/31/2021 |
| Use of Medical Imaging |
| OP-8. MRI Lumbar Spine for Low Back Pain | 07/01/2019 | 12/31/2019 |
| OP-10. Abdomen CT - Use of Contrast Material | 07/01/2019 | 12/31/2019 |
| OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery | 07/01/2019 | 12/31/2019 |
| Medicare Spending Per Beneficiary |
| MSPB. Medicare Spending per Beneficiary | 07/01/2020 | 12/31/2020 |
| Cataract Surgery Outcome |
| OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 01/01/2020 | 12/31/2020 |
| Colonoscopy care |
| OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 01/01/2020 | 12/31/2020 |
| IPFQR |
| HBIPS-2. Hours of physical-restraint use | 01/01/2020 | 12/31/2020 |
| HBIPS-3. Hours of seclusion | 01/01/2020 | 12/31/2020 |
| HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification | 01/01/2020 | 12/31/2020 |
| READM-30-IPF. Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility | 07/01/2018 | 12/31/2019 |
| SMD. Screening for metabolic disorders | 01/01/2020 | 12/31/2020 |
| SUB-2. Alcohol use brief intervention provided or offered | 01/01/2020 | 12/31/2020 |
| SUB-2A. Alcohol use brief intervention received | 01/01/2020 | 12/31/2020 |
| SUB-3. Alcohol and other drug use disorder treatment provided or offered at discharge | 01/01/2020 | 12/31/2020 |
| SUB-3A. Alcohol and other drug use disorder treatment receieved | 01/01/2020 | 12/31/2020 |
| TOB-2. Tobacco use treatment provided or offered | 01/01/2020 | 12/31/2020 |
| TOB-2A. Tobacco use treatment received | 01/01/2020 | 12/31/2020 |
| TOB-3. Tobacco use treatment provided or offered at discharge | 01/01/2020 | 12/31/2020 |
| TOB-3A. Tobacco use treatment received at discharge | 01/01/2020 | 12/31/2020 |
| FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days | 07/01/2019 | 12/31/2019 |
| FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days | 07/01/2019 | 12/31/2019 |
