No

Percentage of surgery patients with recommended Venous Thromboembolism (VTE) Prophylaxis ordered during admission

Percentage of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure.

Annual procedural volume of three surgeries: isolated CABG surgery, valve surgery, and valve + CABG surgery.

Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool

A reliability adjusted measure of AAA repair performance that optimally combines two important domains: AAA hospital volume and AAA operative mortality, to provide predictions on hospital AAA survival rates in patients age 18 and over.

A reliability adjusted measure of Esophagectomy surgical performance that optimally combines two important domains: Esophagectomy hospital volume and Esophagectomy operative mortality, to provide predictions on hospital Esophagectomy survival rates in patients age 18 and over.

A reliability adjusted measure of pancreatic resection surgical performance that optimally combines two important domains: Pancreatic resection hospital volume and pancreatic operative mortality, to provide predictions on hospital pancreatic survival rates in patients age 18 and.

Documents the extent to which a provider uses certified/qualified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data into the EHR as discrete searchable data elements.

Documents the extent to which a provider uses a certified/qualified electronic health record (EHR) system capable of enhancing care management at the point of care. To qualify, the facility must have implemented processes within their EHR for disease management that incorporate the principles of care management at the point of care which include:
a. The ability to identify specific patients by diagnosis or medication use
b. The capacity to present alerts to the clinician for disease management, preventive services and wellness

This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.