Hospital Inpatient Quality Reporting

Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM)of hospital-onset unique blood source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility

Participation in a clinical database with broad state, regional, or national representation, that provides regular performance reports based on benchmarked data

The PSI 90 composite measure summarizes patient safety across multiple indicators for the CMS Medicare fee-for-service population.

Inpatients age 65 years and older and 5-64 years of age who have a high risk condition who are screened for Pneumococcal Vaccine status and vaccinated prior to discharge if indicated.

Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time. The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery.

This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.

This is a hospital level performance score reported as the percent of infants with Unexpected Newborn Complications among full term newborns with no preexisting conditions, typically calculated per year.