Regulatory and Accreditation Programs

This measure assesses the proportion of pediatric asthma patients discharged from an inpatient hospital stay with a Home Management Plan of Care (HMPC) document in place. This measure is one of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, and CAC-2: Systemic Corticosteroids for Inpatient Asthma) that are used in The Joint Commission’s accreditation process.

The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey 3.0 (CG-CAHPS) is a standardized survey instrument that asks patients to report on their experiences with primary or specialty care received from providers and their staff in ambulatory care settings over the preceding 6 months.

Percentage of stress SPECT MPI, stress echo, CCTA, or CMR performed in low risk surgery patients for preoperative evaluation

Percentage of all stress SPECT MPI, stress echo, CCTA and CMR performed routinely after PCI, with reference to timing of test after PCI and symptom status.

Percentage of all stress SPECT MPI, stress echo, CCTA, and CMR performed in asymptomatic, low CHD risk patients for initial detection and risk assessment

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.   SIR is reported annually and is calculated by dividing the number of observed CAUTIs into the number of predicted CAUTIs. 

Annual risk-adjusted standardized infection ratio (SIR) of central line-associated bloodstream infections (CLABSI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, and long-term acute care hospitals. SIR is reported annually and is calculated by dividing the number of observed CLABSIs by the number of predicted CLABSIs.   

The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
-Women 21–64 years of age who had cervical cytology performed within the last 3 years.
-Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
-Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years.

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care.

The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:


Communication with Parent
1. Communication between you and your child’s nurses (3 items)

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine.