Regulatory and Accreditation Programs

This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the emergency department (ED) within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. The measure is calculated using chart abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

Percentage of patients with advanced chronic disease (CKD4 or 5) or end-stage renal disease (ESRD) undergoing open surgical implantation of permanent hemodialysis access who receive an autogenous arterial venous fistula(AVF).

Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies

Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year

A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

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.

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).

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.

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.

Percentage of healthcare personnel (HCP) who receive the influenza vaccination.

This measure assesses the degree to which the organization initiates and engages members identified with a need for alcohol and other drug (AOD) abuse and dependence services and the degree to which members initiate and continue treatment once the need has been identified. Two rates are reported: