Quality Improvement (Internal to the specific organization)

Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer

The Breast Cancer Screening Recall Rates measure calculates the percentage of beneficiaries with mammography or digital breast tomosynthesis (DBT) screening studies that are followed by a diagnostic mammography, DBT, ultrasound, or magnetic resonance imaging (MRI) of the breast in an outpatient or office setting within 45 days.

Percentage of female patients aged 18 years and older with Stage I (T1b) through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period

Use of relievers in pediatric patients, age 2 years through 17 years, admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-2: Systemic Corticosteroids for Inpatient Asthma, and CAC-03: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver) that are used in The Joint Commission’s accreditation process.

Use of systemic corticosteroids in pediatric asthma patients (age 2 through 17 years) admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, CAC-3: Home Management Plan of Care (HMPC) Document Given to Parent/Caregiver) that are used in The Joint Commission’s accreditation process.

This measure assesses the proportion of pediatric asthma patients discharged from an inpatient hospital stay with a Home Management Plan of Care (HMPC) document in place. This measure is one of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, and CAC-2: Systemic Corticosteroids for Inpatient Asthma) that are used in The Joint Commission’s accreditation process.

The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey 3.0 (CG-CAHPS) is a standardized survey instrument that asks patients to report on their experiences with primary or specialty care received from providers and their staff in ambulatory care settings over the preceding 6 months.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey, also referred as the "CAHPS Home Health Care Survey" or "Home Health CAHPS" or “HHCAHPS” is a standardized survey instrument and data collection methodology for measuring home health patients ‘perspectives on their home health care in Medicare-certified home health care agencies. AHRQ and CMS participated in the development of the Home Health CAHPS to measure the experiences of those receiving home health care with these three goals in mind: 

Intravenous insulin glycemic control protocol implemented for cardiac surgery patients with diabetes or hyperglycemia admitted into an intensive care unit

Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.