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).
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 adult patients (aged 18 and over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed
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
Percentage of SUI surgeries for which cystoscopy was used during the surgical procedure to reduce complications
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.
This is a hospital based, risk adjusted, case mix adjusted elderly surgery aggregate clinical outcomes measure of adults 65 years of age and older.
This is a hospital based, risk adjusted, case mix adjusted morbidity and mortality aggregate outcome measure of adults 18+ years undergoing colon surgery.