No risk adjustment or risk stratification

The percentage of patients 18 years of age and older who were discharged from an inpatient setting with an acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) during the 12 months prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had documentation of routine use of aspirin or another antiplatelet during the measurement year.

This measure is used to assess the percent of patient visits and admissions where preferred spoken language for health care is screened and recorded.

This measure is used to assess the percentage of limited English-proficient (LEP) patients receiving both initial assessment and discharge instructions supported by assessed and trained interpreters or from bilingual providers and bilingual workers/employees assessed for language proficiency.

Percentage of patients age 50 and over with fragility fracture who have had appropriate laboratory investigation for secondary causes of fracture ordered or performed prior to discharge from inpatient status.

0-100 measure of language services related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit (C-CAT)

Percentage of physician mechanisms used to evaluate patient experience based on evidence of the following. •An ongoing system for obtaining feedback about patient experience with care •A process for analyzing the data and a plan for improving patient experience. Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records.

Percentage of patients provided with educational materials that review the natural history of the disease and treatment options, including alternatives to surgery, the risks and benefits and the evidence.
Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records.

Percentage of post-surgical outcomes examined by a physician's system that includes the following. •Tracking specific complications of back surgery; •Periodic analysis of surgical complications data and a plan for improving outcomes. Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. This standard is applicable only for physicians who perform surgery.

0-100 measure of leadership commitment to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

Percent of patients leaving without being seen by a qualified medical personnel.