Quality Improvement (Internal to the specific organization)

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

Percentage of patients who report being uncomfortable because of pain at the initial assessment who, at the follow up assessment, report pain was brought to a comfortable level within 48 hours.

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed

Percentage of patients with audited colorectal cancer resection pathology complete reports

This is a weighted composite measure comprised of six component measures: three all-cause risk standardized outcome measures on all-cause mortality, bleeding, acute kidney injury and three process measures focused on discharge on guideline directed medical therapy, referral to a cardiac rehabilitation program and PCI performed within ninety minutes of symptoms for patients with acute myocardial infarctions. The target population includes adults (age 18 and greater) undergoing percutaneous coronary interventions. The timeframe for reporting will be a rolling four quarters.