Quality Improvement (Internal to the specific organization)

Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on beta blockers

Proportion of ICD implant patients with a diagnosis of Left Ventricular Systolic Dysfunction who are prescribed beta-blocker therapy on discharge.

Number of procedures for which the patient was discharged from the facility on beta blockers/ Number of Isolated CABG procedures excluding those that resulted in in-hospital mortalities based on the variables Mortality Discharge Status, Mortality Date, and Discharge Date

Proportion of heart failure patients age 18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Bilateral cardiac catheterization discharges per 1,000 heart catheterizations discharges for coronary artery disease for patients ages 18 years and older. Excludes valid indications for right- side catheterization discharges and obstetric discharges.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report specific procedure discharges per 1,000 hospital discharges.]

Percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care/referring physician and the patient.

This measure identifies the percentage of patients with newly diagnosed bipolar disorder who have received at least 1 prescription for a mood-stabilizing agent during the measurement year.

Percentage of patients treated for depression who were assessed, prior to treatment, for the presence of current and/or prior manic or hypomanic behaviors.

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

Percentage of patients with bipolar disorder with evidence of an initial assessment that includes an appraisal for risk of suicide.