No risk adjustment or risk stratification

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

The number of hospital discharges with a pediatric heart surgery procedure for patients with congential heart disease ages 17 years and younger.

The measure requires hospitals and output facilities that conduct Computed Tomography (CT) studies to assess the radiation dose associated with the most frequently conducted examination types – CT’s of the head, chest, abdomen/pelvis obtained in children and adults. The measure provides a simple framework for how facilities can assess their dose, a framework that currently does not exist. By assessing their doses, facilities can monitor the doses they use over time and compare their doses to benchmarks. The creation of benchmarks is not part of this measure per se.

Percentage of female patients, age = 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the breast, had breast conserving surgery and was administered radiation therapy within 1 year (365 days) of diagnosis

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.

Percentage of adult patients (aged 18 and over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed

Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA)who are discharged alive. This measure is proposed for both hospitals and individual providers. At present, this measure is reported via the Vascular Quality Initiative (VQI) Registry.

Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical staging provided prior to surgery

Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had their performance status recorded within two weeks prior to the surgery date

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 17 years and younger. Excludes normal newborns, newborns with birth weight less than 500 grams, cases with principal diagnosis of retained surgical item or unretrieved device fragment, cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission, and obstetric cases.