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Quality Definitions and Methodology

Collection Periods

Measure Collection Period
From To
Hospital Return Days 
EDAC-30-HF. Heart Failure 07/01/2019 06/30/2022
EDAC-30-PN. Pneumonia 07/01/2019 06/30/2022
EDAC_30_AMI. Heart Attack 07/01/2019 06/30/2022
Visit Rates Following OP Procedure 
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy 01/01/2022 12/31/2022
OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 01/01/2022 12/31/2022
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery 01/01/2022 12/31/2022
Readmission Reduction 
READM-30-AMI-HRRP. Heart Attack 07/01/2019 06/30/2022
READM-30-HF-HRRP. Heart Failure 07/01/2019 06/30/2022
READM-30-PN-HRRP. Pneumonia 07/01/2019 06/30/2022
READM-30-COPD-HRRP. COPD 07/01/2019 06/30/2022
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery 07/01/2019 06/30/2022
Timely Heart Attack Care 
OP-2. Fibrinolytic Therapy received within 30 minutes 04/01/2022 03/31/2023
OP-3b. Median Time to transfer patients for Acute Coronary Intervention 04/01/2022 03/31/2023
Timely Emergency Department Care 
OP-18b. Average time patients spent in the emergency department before being sent home 04/01/2022 03/31/2023
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 04/01/2022 03/31/2023
OP-22. Percentage of patients who left the emergency department before being seen 01/01/2022 12/31/2022
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 04/01/2022 03/31/2023
Blood Clot Prevention 
VTE-1. Patients who received treatment to prevent blood clots within one day of admission or the day after surgery 01/01/2022 12/31/2022
VTE-2. ICU patients who received treatment to prevent blood clots within one day of admission, within one day of transfer to the ICU, or within one day following surgery 01/01/2022 12/31/2022
Pregnancy and Delivery Care 
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary 04/01/2022 03/31/2023
Survey of Patient Hospital Experiences 
HCAHPS. Patient Survey Results 04/01/2022 03/31/2023
30-Day Risk Adjusted Mortality Rates 
MORT-30-CABG. CABG 07/01/2019 06/30/2022
MORT-AMI. Heart Attack 07/01/2019 06/30/2022
MORT-HF. Heart Failure 07/01/2019 06/30/2022
MORT-PN. Pneumonia 07/01/2019 06/30/2022
MORT-30-COPD. COPD 07/01/2019 06/30/2022
MORT-30-STK. Stroke 07/01/2019 06/30/2022
30-Day Risk Adjusted Readmission Rates 
OP-32. Colonoscopy 01/01/2020 12/31/2022
READM-30-CABG. CABG 07/01/2019 06/30/2022
READM-AMI. Heart Attack 07/01/2019 06/30/2022
READM-HF. Heart Failure 07/01/2019 06/30/2022
READM-PN. Pneumonia 07/01/2019 06/30/2022
READM-30-COPD. COPD 07/01/2019 06/30/2022
READM-30-HIP-KNEE. Hip/Knee Surgery 07/01/2019 06/30/2022
READM-30-HOSPWIDE. Hospital-wide 07/01/2021 06/30/2022
Surgical Complications 
Complications for Hip/Knee Replacements 04/01/2019 03/31/2022
PSI-10. Postoperative Acute Kidney Injury Rate 07/01/2020 06/30/2022
PSI-11. Postoperative Respiratory Failure Rate 07/01/2020 06/30/2022
PSI-12. Serious blood clots after surgery 07/01/2020 06/30/2022
PSI-13. Blood stream infection after surgery 07/01/2020 06/30/2022
PSI-14. A wound that splits open after surgery 07/01/2020 06/30/2022
PSI-15. Accidental cuts and tears from medical treatment 07/01/2020 06/30/2022
PSI-90. Serious Complications 07/01/2020 06/30/2022
Healthcare Associated Infections 
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 04/01/2022 03/31/2023
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 04/01/2022 03/31/2023
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 04/01/2022 03/31/2023
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 04/01/2022 03/31/2023
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 04/01/2022 03/31/2023
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 04/01/2022 03/31/2023
Use of Medical Imaging 
OP-8. MRI Lumbar Spine for Low Back Pain 07/01/2021 06/30/2022
OP-10. Abdomen CT - Use of Contrast Material 07/01/2021 06/30/2022
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 07/01/2021 06/30/2022
OP-39. Breast Cancer Screening Recall Rates 07/01/2021 06/30/2022
Medicare Spending Per Beneficiary 
MSPB. Medicare Spending per Beneficiary 01/01/2022 12/31/2022
Cataract Surgery Outcome 
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery 01/01/2022 12/31/2022
Colonoscopy care 
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 01/01/2022 12/31/2022
IPFQR 
HBIPS-2. Hours of physical-restraint use 01/01/2022 12/31/2022
HBIPS-3. Hours of seclusion 01/01/2022 12/31/2022
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification 01/01/2022 12/31/2022
READM-30-IPF. Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility 07/01/2020 06/30/2022
SMD. Screening for metabolic disorders 01/01/2022 12/31/2022
SUB-2. Alcohol use brief intervention provided or offered 01/01/2022 12/31/2022
SUB-2A. Alcohol use brief intervention received 01/01/2022 12/31/2022
SUB-3. Alcohol and other drug use disorder treatment provided or offered at discharge 01/01/2022 12/31/2022
SUB-3A. Alcohol and other drug use disorder treatment receieved 01/01/2022 12/31/2022
TOB-2. Tobacco use treatment provided or offered 01/01/2022 12/31/2022
TOB-2A. Tobacco use treatment received 01/01/2022 12/31/2022
TOB-3. Tobacco use treatment provided or offered at discharge 01/01/2022 12/31/2022
TOB-3A. Tobacco use treatment received at discharge 01/01/2022 12/31/2022