Professional Certification or Recognition Program

The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (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 measurement year, who had each of the following during the measurement year.

- Complete Lipid Profile
- LDL-C control <100 mg/dL

The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

Composite 1: Patient-Centered Access
Composite 2: Team-Based Care
Composite 3: Population Health Management
Composite 4: Care Management and Support
Composite 5: Care Coordination and Care Transitions

Percentage of patient visits, regardless of age, seen with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month reporting period, into a recall system that includes:
• A target date for the next complete physical skin exam , AND
• A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM)of hospital-onset unique blood source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility

NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

Measure focus is structure of care quality in acute care hospital units.

Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

Percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to the physician(s) providing continuing care and to the patient within one month of completing treatment

Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have cancer staging documented using any standardized system or documentation that the cancer is metastatic in the medical record within one month of first office visit

This measure looks at the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients with a diagnosis of cancer who are also currently receiving chemotherapy or radiation therapy during the measurement period.