Endorsement Removed

Discharges with a principal diagnosis of community acquired bacterial pneumonia per 100,000 population, age 18 or older. Excludes sickle cell or hemoglobin-S admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed

Percentage of patients with audited colorectal cancer resection pathology complete reports

The percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:
- Hemoglobin A1c (HbA1c) testing (NQF#0057)
- HbA1c poor control (>9.0%) (NQF#0059)
- HbA1c control (<8.0%) (NQF#0575)
- HbA1c control (<7.0%) for a selected population*
- Eye exam (retinal) performed (NQF#0055)
- LDL-C screening (NQF#0063)
- LDL-C control (<100 mg/dL) (NQF#0064)
- Medical attention for nephropathy (NQF#0062)
- BP control (<140/90 mm Hg) (NQF#0061)
- Smoking status and cessation advice or treatment

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received an HbA1c test during the measurement year.

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent LDL-C test is <100 mg/dL during the measurement year.

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who received an LDL-C test during the measurement year.

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening test or monitoring test or had evidence of nephropathy during the measurement year.

Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with the diagnosis of ischemic stroke or TIA or intracranial hemorrhage that includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Any time an endotracheal tube is placed into a patients airway in the Emergency Department (ED)or a patient arrives to the ED with an endotracheal tube already in place ( via EMS or hospital transfer) there should be appropriate confirmation of ETT placement and documentation of its performance in the medical record.