No risk adjustment or risk stratification

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge.

Rate 1 (SAC): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler during the same 90-day period.

Rate 2 (ACT): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of short-acting beta2 agonist inhalers over a 90-day period and who did not receive controller therapy during the same 90-day period.

Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

The percentage of children 6 months of age who had Suddent Infant Death Syndrome (SIDS) counseling.

Percentage of patients on beta blocker therapy prior to arrival who received a beta blocker during the perioperative period. To be in the denominator, the patient must be on a beta-blocker prior to arrival. The case is excluded if the patient is not on a beta-blocker prior to arrival.

Percentage of surgery patients who received appropriate Venous Thromboembolism (VTE) Prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time.

Percentage of surgery patients with surgical hair site removal with clippers or depilatory or no surgical site hair removal.

Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° F/36° C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time.

Documents the extent to which a provider uses certified/qualified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data into the EHR as discrete searchable data elements.

Documents the extent to which a provider uses a certified/qualified electronic health record (EHR) system capable of enhancing care management at the point of care. To qualify, the facility must have implemented processes within their EHR for disease management that incorporate the principles of care management at the point of care which include:
a. The ability to identify specific patients by diagnosis or medication use
b. The capacity to present alerts to the clinician for disease management, preventive services and wellness