Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting

Percentage of patients, age = 18 and < 80 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy) that is lymph node positive and at AJCC stage III, whose primary tumor is of the colon and chemotherapy was recommended or administered within 4 months (120 days) of diagnosis

Percentage of female patients, age = 18 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC T1cN0M0 or stage IB to IIIC, whose primary tumor is of the breast, and is progesterone or estrogen receptor positive with adjuvant hormonal therapy (recommended or administered) within 1 year (365 days) of diagnosis

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

Percentage of female patients, age >= 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC stage T1cN0M0 or Stage IB - IIIC, whose primary tumor is of the breast, and progesterone and estrogen receptor negative is recommended or administered multi-agent chemotherapy within 4 months (120 days) of diagnosis

This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.

HCAHPS (NQF #0166) is a 29-item survey instrument that produces 10 publicly reported measures:

6 multi-item measures (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, discharge information and care transition); and

4 single-item measures (cleanliness of the hospital environment, quietness of the hospital environment, overall rating of the hospital, and recommendation of hospital).

Percentage of healthcare personnel (HCP) who receive the influenza vaccination.

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

Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

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.