Quality Improvement (Internal to the specific organization)

Percentage of patients with COPD with oxygen saturation assessed at least annually

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period for whom there is documented results of an evaluation of level of activity AND an evaluation of presence or absence of anginal symptoms in the medical record

These measures are based on the CAHPS Cultural Competence Item Set, a set of supplemental items for the CAHPS Clinician/Group Survey that includes the following domains: Patient-provider communication; Complementary and alternative medicine; Experiences of discrimination due to race/ethnicity, insurance, or language; Experiences leading to trust or distrust, including level of trust, caring and confidence in the truthfulness of their provide; and Linguistic competency (Access to language services).

These measures are based on the CAHPS Item Set for Addressing Health Literacy, a set of supplemental items for the CAHPS Clinician & Group Survey. The item set includes the following domains: Communication with Provider (Doctor), Disease Self-Management, Communication about Medicines, Communication about Test Results, and Communication about Forms. Samples for the survey are drawn from adults who have had at least one provider´s visit within the past year. Measures can be calculated at the individual clinician level, or at the group (e.g., practice, clinic) level.

CollaboRATE is a patient-reported measure of shared decision making which contains three brief questions that patients, their parents, or their representatives complete following a clinical encounter. The CollaboRATE measure provides a performance score representing the percentage of adults 18 and older who experience a high level of shared decision making.

Percentage of patients aged 18 years through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12-month reporting period

Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade

The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.

Percentage of female patients, age >= 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC stage T1cN0M0 or Stage IB - IIIC, whose primary tumor is of the breast, and progesterone and estrogen receptor negative is recommended or administered multi-agent chemotherapy within 4 months (120 days) of diagnosis