Inpatient/Hospital

Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time

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.

Percentage of patients who died with documented or undocumented complications within 30 days from admission

Assesses different facets of fall risk management:

Discussing Fall Risk. The percentage of adults 75 years of age and older, or 65–74 years of age with balance or walking problems or a fall in the past 12 months, who were seen by a practitioner in the past 12 months and who discussed falls or problems with balance or walking with their current practitioner.

All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

(Total number of injury falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

This measure calculates the percentage of Emergency Department (ED) acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. The measure is calculated using chart-abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

Percentage of acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.

Proportion of infants with birth weights between 501 to 1500 grams with first temperature measured within one hour of admission to the neonatal intensive care unit (NICU) below 36 degrees centigrade.

Percent of NICU admissions with a birth weight of 501-1500g with a first temperature taken within 1 hour of NICU admission.

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) and a current or prior ejection fraction (EF) <40% who are self-identified Black or African Americans and receiving ACEI or ARB and Beta-blocker therapy who were prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge