Quality Improvement (Internal to the specific organization)

Percentage of ICU and HRN patients who over a certain amoint of days have ventilator-associated pneumonia

This measure is a 30-day malfunction rate for hospitals that perform cerebrospinal ventriculoperitoneal shunt operations in children between the ages of 0 and 18 years.

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

This metric is designed to measure the critical care transport team's utilization of waveform capnography during critical care medical transport.  Waveform capnography has evolved as the standard for the safe placement and maintenance of advanced airways (e.g., endotracheal tubes) in adult and pediatric patients.  The metric specifically focuses on transported patients with advanced airways in whom continuous waveform capnography is appropriately used.  This metric is stratified by age into the following three categories: neonatal (defined as infants <29 days), pediatric (

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

Percentage of ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event.

A Wrong-Patient Retract-and-Reorder (Wrong Patient-RAR) event occurs when an order is placed on a patient within an EHR, is retracted within 10 minutes, and then the same clinician places the same order on a different patient within the next 10 minutes. A Wrong-Patient Retract-and-Reorder rate is calculated by dividing Wrong Patient-RAR events by total orders examined.