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Regulatory and Accreditation Programs

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

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

Medication Management for People with Asthma

  • The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported.
    1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period.
    2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period.

    CBE ID
    1799

Medication Reconciliation Post-Discharge

  • The percentage of discharges from January 1–December 1 of the measurement year for patients 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 days total).

    CBE ID
    0097

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

    CBE ID
    0139

Optimal Diabetes Care

  • The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:
    • HbA1c less than 8.0 mg/dL
    • Blood Pressure less than 140/90 mmHg
    • On a statin medication, unless allowed contraindications or exceptions are present
    • Non-tobacco user
    • Patient with ischemic vascular disease is on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present

    CBE ID
    0729