No risk adjustment or risk stratification

Percentage of intensive care unit patients on mechanical ventilation
at time of survey for whom all five elements of the ventilator bundle are documented and in place. The ventilator bundle elements are:
•Head of bed (HOB) elevation 30 degrees or greater (unless medically contraindicated)
•Daily “”sedation interruption” and daily assessment of readiness to extubate •Peptic ulcer disease prophylaxis
•Deep Venous Thrombosis prophylaxis
•Daily oral care with Chlorhexidine

Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that the entire vital signs record was communicated to the receiving FACILITY within 60 minutes of departure

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed

NSC-11.1 Total number of full-time and part-time Registered Nurse (RN) and Advanced Practice Nurse (APN) voluntary uncontrolled separations occurring during the calendar month
NSC-11.2 Total number of full-time and part-time Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) voluntary uncontrolled separations occurring during the calendar month
NSC-11.3 Total number of full-time and part-time Unlicensed Assistive Personnel (UAP) voluntary uncontrolled separations occurring during the calendar month

The percentage of patients taking warfarin who had PT/INR monitoring

This measure identifies the percentage of patients taking warfarin during the measurement year who had at least one PT/INR test within 30 days after the first warfarin prescription in the measurement year

Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year:
- Body mass index (BMI) percentile documentation
- Counseling for nutrition
- Counseling for physical activity

Percentage of children 15 months old who had well-child visits with a primary care physician during the measurement year.

The percentage of children 3-6 years of age who had one or more well-child visits with a primary care physician during the measurement year.

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