| Readmission Reduction |
| READM-30-AMI-HRRP. Heart Attack | 7/1/2012 | 6/30/2015 |
| READM-30-HF-HRRP. Heart Failure | 7/1/2012 | 6/30/2015 |
| READM-30-PN-HRRP. Pneumonia | 7/1/2012 | 6/30/2015 |
| READM-30-COPD-HRRP. COPD | 7/1/2012 | 6/30/2015 |
| READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery | 7/1/2012 | 6/30/2015 |
| Timely Heart Attack Care |
| OP-1. Median Time to Fibrinolysis | 7/1/2015 | 3/31/2016 |
| OP-2. Fibrinolytic Therapy received within 30 minutes | 7/1/2015 | 3/31/2016 |
| OP-3b. Median Time to transfer patients for Acute Coronary Intervention | 7/1/2015 | 3/31/2016 |
| OP-4. Aspirin at Arrival | 7/1/2015 | 3/31/2016 |
| OP-5. Median Time to ECG | 7/1/2015 | 3/31/2016 |
| Timely Emergency Department Care |
| ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient | 7/1/2015 | 6/30/2016 |
| ED-2b. Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room | 7/1/2015 | 6/30/2016 |
| OP-18b. Average time patients spent in the emergency department before being sent home | 7/1/2015 | 3/31/2016 |
| OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional | 7/1/2015 | 3/31/2016 |
| OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication | 7/1/2015 | 3/31/2016 |
| OP-22. Percentage of patients who left the emergency department before being seen | 1/1/2015 | 12/31/2015 |
| OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival | 7/1/2015 | 3/31/2016 |
| Preventative Care |
| IMM-2. Patients assessed and given influenza vaccination | 10/1/2015 | 3/31/2016 |
| Timely Stroke Care |
| STK-4. Ischemic stroke patients who received t-PA within 3 hours of symptoms | 7/1/2015 | 6/30/2016 |
| Blood Clot Prevention |
| VTE-5. Patients with blood clots who were discharged on blood thinners and received educational instructions at discharge | 7/1/2015 | 6/30/2016 |
| VTE-6. Patients who developed blood clots who did not receive preventative treatment | 7/1/2015 | 6/30/2016 |
| Pregnancy and Delivery Care |
| PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary | 7/1/2015 | 6/30/2016 |
| Survey of Patient Hospital Experiences |
| HCAHPS. Patient Survey Results | 7/1/2015 | 6/30/2016 |
| 30-Day Risk Adjusted Mortality Rates |
| MORT-30-CABG. CABG | 7/1/2012 | 6/30/2015 |
| MORT-AMI. Heart Attack | 7/1/2012 | 6/30/2015 |
| MORT-HF. Heart Failure | 7/1/2012 | 6/30/2015 |
| MORT-PN. Pneumonia | 7/1/2012 | 6/30/2015 |
| MORT-30-COPD. COPD | 7/1/2012 | 6/30/2015 |
| MORT-30-STK. Stroke | 7/1/2012 | 6/30/2015 |
| 30-Day Risk Adjusted Readmission Rates |
| READM-30-CABG. CABG | 7/1/2012 | 6/30/2015 |
| READM-AMI. Heart Attack | 7/1/2012 | 6/30/2015 |
| READM-HF. Heart Failure | 7/1/2012 | 6/30/2015 |
| READM-PN. Pneumonia | 7/1/2012 | 6/30/2015 |
| READM-30-COPD. COPD | 7/1/2012 | 6/30/2015 |
| READM-30-HIP-KNEE. Hip/Knee Surgery | 7/1/2012 | 6/30/2015 |
| READM-30-STK. Stroke | 7/1/2012 | 6/30/2015 |
| READM-30-HOSPWIDE. Hospital-wide | 7/1/2014 | 6/30/2015 |
| Surgical Complications |
| Complications for Hip/Knee Replacements | 4/1/2012 | 3/31/2015 |
| PSI-4. Death from serious treatable complications after surgery | 7/1/2013 | 6/30/2015 |
| PSI-6. Collapsed lung due to medical treatment | 7/1/2013 | 6/30/2015 |
| PSI-12. Serious blood clots after surgery | 7/1/2013 | 6/30/2015 |
| PSI-14. A wound that splits open after surgery | 7/1/2013 | 6/30/2015 |
| PSI-15. Accidental cuts and tears from medical treatment | 7/1/2013 | 6/30/2015 |
| PSI-90. Serious Complications | 7/1/2013 | 6/30/2015 |
| Healthcare Associated Infections |
| HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) | 7/1/2015 | 6/30/2016 |
| HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) | 7/1/2015 | 6/30/2016 |
| HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) | 7/1/2015 | 6/30/2016 |
| HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) | 7/1/2015 | 6/30/2016 |
| HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections | 7/1/2015 | 6/30/2016 |
| HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) | 7/1/2015 | 6/30/2016 |
| Use of Medical Imaging |
| OP-8. MRI Lumbar Spine for Low Back Pain | 7/1/2014 | 6/30/2015 |
| OP-9. Mammography Follow-up Rates | 7/1/2014 | 6/30/2015 |
| OP-10. Abdomen CT - Use of Contrast Material | 7/1/2014 | 6/30/2015 |
| OP-11. Thorax CT - Use of Contrast Material | 7/1/2014 | 6/30/2015 |
| OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery | 7/1/2014 | 6/30/2015 |
| OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time | 7/1/2014 | 6/30/2015 |
| Medicare Spending Per Beneficiary |
| MSPB. Medicare Spending per Beneficiary | 1/1/2015 | 12/31/2015 |
| Cataract Surgery Outcome |
| OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 1/1/2015 | 12/31/2015 |
| Colonoscopy care |
| OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 1/1/2015 | 12/31/2015 |
| OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | 1/1/2015 | 12/31/2015 |
| General |
| OP-25. Safe Surgery Checklist Use | 1/1/2015 | 12/31/2015 |
| OP-26. Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures | 1/1/2015 | 12/31/2015 |
| SM_PART_GEN_SURG. General Surgery Registry | 1/1/2015 | 12/31/2015 |
| IPFQR |
| HBIPS-2. Hours of physical-restraint use | 1/1/2015 | 12/31/2015 |
| HBIPS-3. Hours of seclusion | 1/1/2015 | 12/31/2015 |
| HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification | 1/1/2015 | 12/31/2015 |
| HBIPS-6. Post-discharge continuing care plan created | 1/1/2015 | 12/31/2015 |
| HBIPS-7. Post-discharge continuing care plan transmitted to the next level of care provider upon discharge | 1/1/2015 | 12/31/2015 |
| FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days | 7/1/2014 | 6/30/2015 |
| FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days | 7/1/2014 | 6/30/2015 |
| IMM-2. Influenza Immunization | 10/1/2015 | 3/31/2016 |
