Other Data Source

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.

Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical staging provided prior to surgery

Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had their performance status recorded within two weeks prior to the surgery date

Total number of patients that have vest and/or limb restraint (upper or lower body or both) on the day of the prevalence measurement episode.

Periodic clinical review of unplanned readmissions to the PICU that occurred within 24 hours of discharge or transfer from the PICU.

Percent of Rh negative pregnant women at risk of fetal blood exposure who receive Rhogam the ED.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

This is a hospital based, risk adjusted, case mix adjusted elderly surgery aggregate clinical outcomes measure of adults 65 years of age and older.