Regulatory and Accreditation Programs

The total number of patients that have hospital-acquired (nosocomial) category/stage II or greater pressure ulcers on the day of the prevalence measurement episode.

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

The Promoting Healthy Development Survey (PHDS) is a 43-item parent survey that can be used by health care providers, health systems, Medicaid agencies, and other stakeholders to measure and improve the quality of preventive and developmental care for children ages 0-48 months. The survey is designed to measure parent’s experience with care and the extent to which they received preventative and developmental services in accordance with nationally recommended guidelines put forth by the American Academy of Pediatrics and Bright Futures practice guidelines (3rd edition).1

Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time. The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery.

What percentage of infants had bloodspot newborn screening performed as mandated by state of birth?

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

Percentage of female patients, age = 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the breast, had breast conserving surgery and was administered radiation therapy within 1 year (365 days) of diagnosis