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Regulatory and Accreditation Programs

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Immunizations for Adolescents

  • Percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.

    CBE ID
    1407

Inappropriate diagnosis of community-acquired pneumonia (CAP) in hospitalized medical patients; Abbreviated form: Inappropriate diagnosis of CAP

  • The inappropriate diagnosis of CAP in hospitalized medical patients (or “Inappropriate Diagnosis of CAP”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for CAP who do not meet diagnostic criteria for pneumonia (thus are inappropriately diagnosed and treated).

    CBE ID
    3671

Incidence of Potentially Preventable Venous Thromboembolism

  • This measure assesses the number of patients with confirmed venous thromboembolism (VTE) during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

    CBE ID
    0376

Influenza Immunization

  • Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.

    CBE ID
    1659

Median Time to ECG

  • Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with
    Probable Cardiac Chest Pain).

    CBE ID
    0289

Median Time to Pain Management for Long Bone Fracture

  • Median time from emergency department arrival to time of initial oral, intranasal or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).

    CBE ID
    0662