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Quality Definitions and Methodology

Collection Periods

Measure Collection Period
From To
Hospital Return Days
EDAC-30-HF. Heart Failure07/01/201506/30/2018
EDAC-30-PN. Pneumonia07/01/201506/30/2018
EDAC_30_AMI. Heart Attack07/01/201506/30/2018
Visit Rates Following OP Procedure
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy01/01/201812/31/2018
OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy01/01/201812/31/2018
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery01/01/201812/31/2018
Readmission Reduction
READM-30-AMI-HRRP. Heart Attack07/01/201506/30/2018
READM-30-HF-HRRP. Heart Failure07/01/201506/30/2018
READM-30-PN-HRRP. Pneumonia07/01/201506/30/2018
READM-30-COPD-HRRP. COPD07/01/201506/30/2018
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery07/01/201506/30/2018
Timely Heart Attack Care
OP-2. Fibrinolytic Therapy received within 30 minutes07/01/201806/30/2019
OP-3b. Median Time to transfer patients for Acute Coronary Intervention07/01/201806/30/2019
Timely Emergency Department Care
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 room07/01/201806/30/2019
OP-18b. Average time patients spent in the emergency department before being sent home07/01/201806/30/2019
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients.07/01/201806/30/2019
OP-22. Percentage of patients who left the emergency department before being seen01/01/201812/31/2018
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival07/01/201806/30/2019
Preventive Care
IMM-3-FAC-ADHPCT. Healthcare workers given influenza vaccination10/01/201803/31/2019
Pregnancy and Delivery Care
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary07/01/201806/30/2019
Survey of Patient Hospital Experiences
HCAHPS. Patient Survey Results07/01/201806/30/2019
30-Day Risk Adjusted Mortality Rates
MORT-30-CABG. CABG07/01/201506/30/2018
MORT-AMI. Heart Attack07/01/201506/30/2018
MORT-HF. Heart Failure07/01/201506/30/2018
MORT-PN. Pneumonia07/01/201506/30/2018
MORT-30-COPD. COPD07/01/201506/30/2018
MORT-30-STK. Stroke07/01/201506/30/2018
30-Day Risk Adjusted Readmission Rates
OP-32. Colonoscopy01/01/201612/31/2018
READM-30-CABG. CABG07/01/201506/30/2018
READM-AMI. Heart Attack07/01/201506/30/2018
READM-HF. Heart Failure07/01/201506/30/2018
READM-PN. Pneumonia07/01/201506/30/2018
READM-30-COPD. COPD07/01/201506/30/2018
READM-30-HIP-KNEE. Hip/Knee Surgery07/01/201506/30/2018
READM-30-HOSPWIDE. Hospital-wide07/01/201706/30/2018
Surgical Complications
Complications for Hip/Knee Replacements04/01/201503/31/2018
PSI-4. Death from serious treatable complications after surgery07/01/201606/30/2018
PSI-6. Collapsed lung due to medical treatment07/01/201606/30/2018
PSI-12. Serious blood clots after surgery07/01/201606/30/2018
PSI-14. A wound that splits open after surgery07/01/201606/30/2018
PSI-15. Accidental cuts and tears from medical treatment07/01/201606/30/2018
PSI-90. Serious Complications07/01/201606/30/2018
Healthcare Associated Infections
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)07/01/201806/30/2019
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)07/01/201806/30/2019
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)07/01/201806/30/2019
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy)07/01/201806/30/2019
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections07/01/201806/30/2019
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)07/01/201806/30/2019
Use of Medical Imaging
OP-8. MRI Lumbar Spine for Low Back Pain07/01/201706/30/2018
OP-9. Mammography Follow-up Rates07/01/201706/30/2018
OP-10. Abdomen CT - Use of Contrast Material07/01/201706/30/2018
OP-11. Thorax CT - Use of Contrast Material07/01/201706/30/2018
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery07/01/201706/30/2018
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time07/01/201706/30/2018
Medicare Spending Per Beneficiary
MSPB. Medicare Spending per Beneficiary01/01/201812/31/2018
Cataract Surgery Outcome
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery01/01/201812/31/2018
Colonoscopy care
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients01/01/201812/31/2018
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use01/01/201812/31/2018
IPFQR
HBIPS-2. Hours of physical-restraint use01/01/201812/31/2018
HBIPS-3. Hours of seclusion01/01/201812/31/2018
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification01/01/201812/31/2018
SMD. Screening for metabolic disorders01/01/201812/31/2018
SUB-2. Alcohol use brief intervention provided or offered01/01/201812/31/2018
SUB-2A. Alcohol use brief intervention received01/01/201812/31/2018
SUB-3. Alcohol and other drug use disorder treatment provided or offered at discharge01/01/201812/31/2018
SUB-3A. Alcohol and other drug use disorder treatment receieved01/01/201812/31/2018
TOB-2. Tobacco use treatment provided or offered01/01/201812/31/2018
TOB-2A. Tobacco use treatment received01/01/201812/31/2018
TOB-3. Tobacco use treatment provided or offered at discharge01/01/201812/31/2018
TOB-3A. Tobacco use treatment received at discharge01/01/201812/31/2018
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days07/01/201706/30/2018
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days07/01/201706/30/2018