Other Data Source

Rate of ASC patients who received IV antibiotics ordered for surgical site infection prophylaxis on time

Percentage of patients who died from cancer dying in an acute care setting

Proportion of infants 22 to 29 weeks gestation treated with surfactant within 2 hours of birth among infants who were treated with surfactant.

What percentage of infants had bloodspot newborn screening performed as mandated by state of birth?

Percentage of patients who died from cancer with more than one hospitalization in the last 30 days of life

Percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT)

Percentage of patients with quantitative breast tumor HER2 IHC evaluation using the ASCO/CAP recommended manual system or a computer-assisted system consistent with the optimal algorithm for HER2 testing as described in the current ASCO/CAP guidelines.

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).

The measure requires hospitals and output facilities that conduct Computed Tomography (CT) studies to assess the radiation dose associated with the most frequently conducted examination types – CT’s of the head, chest, abdomen/pelvis obtained in children and adults. The measure provides a simple framework for how facilities can assess their dose, a framework that currently does not exist. By assessing their doses, facilities can monitor the doses they use over time and compare their doses to benchmarks. The creation of benchmarks is not part of this measure per se.

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.