Regulatory and Accreditation Programs

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

Percent of Rh negative pregnant women at risk of fetal blood exposure who receive Rhogam the ED.

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge.

Standardized average length of hospital stay (ALOS) for routine inpatient care (i.e., care provided outside of intensive care units).

Ratio of observed to expected major adverse events (MAE) among patients undergoing congenital cardiac catheterization, risk-adjusted using the Catheterization for Congenital Heart Disease Adjustment for Risk Method II (CHARM II).

This measure captures the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

This measure captures the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

This measure captures the proportion of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two (with the day of arrival being day 1).

This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.