The STS Individual Surgeon Composite Measure for Adult Cardiac Surgery includes five major procedures (isolated CABG, isolated AVR, AVR+CABG, MVRR, MVRR+CABG) and comprises the following two domains:

Domain 1 – Risk-Adjusted Operative Mortality
Operative mortality is defined as death before hospital discharge or within 30 days of the operation.

Domain 2 – Risk-Adjusted Major Morbidity
Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation,
2. Deep sternal wound infection,

This measure is for the risk-adjusted Standardized Infection Ratio (SIR) for all Surgical Site Infections (SSI) following breast procedures conducted at ambulatory surgery centers (ASCs) among adult patients (ages 18 - 108 years) and reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measure compares the reported number of surgical site infections observed at an ASC with a predicted value based on nationally aggregated data.

The quarterly incidence rate of falls with injury amongst PACE participants per 1,000 participant days.

The quarterly incidence rate of falls amongst PACE participants per 1,000 participant days.

Prevalence of PACE-acquired pressure ulcers/injuries (Stages 3, 4, unstageable, and deep tissue injury) among PACE participants in a quarter, expressed as persons with 1 or more pressure ulcers/injuries divided by the number of participants on the PACE organization’s census who resided in a home setting (home or assisted living facility)for at least one day during the quarter.

The percentage of patients 65 years of age and older who have evidence of an underlying disease, condition or health concern and who are dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Three rates are reported for this measure:
-Rate 1: The percentage of those with a history of falls that received a potentially harmful medication
-Rate 2: The percentage of those with dementia that received a potentially harmful medication

Percentage of patient-months for which medication reconciliation* was performed and documented by an eligible professional.**

Percentage of laboratory potassium samples drawn in the emergency department (ED) with hemolysis.

The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.

Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access.