American College of Surgeons

Percentage of patients, age = 18 and < 80 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy) that is lymph node positive and at AJCC stage III, whose primary tumor is of the colon and chemotherapy was recommended or administered within 4 months (120 days) of diagnosis

Percentage of female patients, age = 18 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC T1cN0M0 or stage IB to IIIC, whose primary tumor is of the breast, and is progesterone or estrogen receptor positive with adjuvant hormonal therapy (recommended or administered) within 1 year (365 days) of diagnosis

Percentage of patients, age >=18 and <= 120 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the colon, and had at least 12 regional lymph nodes removed and pathologically examined for resected colon cancer

Percentage of female patients, age >= 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC stage T1cN0M0 or Stage IB - IIIC, whose primary tumor is of the breast, and progesterone and estrogen receptor negative is recommended or administered multi-agent chemotherapy within 4 months (120 days) of diagnosis

Percentage of patients with audited colorectal cancer resection pathology complete reports

The following 6 composites and 1 single-item measure are generated from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surgical Care Survey. Each measure is used to assess a particular domain of surgical care quality from the patient’s perspective.

Measure 1: Information to help you prepare for surgery (2 items)
Measure 2: How well surgeon communicates with patients before surgery (4 items)
Measure 3: Surgeon’s attentiveness on day of surgery (2 items)
Measure 4: Information to help you recover from surgery (4 items)

Hospital specific risk-adjusted measure of mortality or one or more of the following major complications (cardiac arrest, myocardial infarction, CVA/stroke, on ventilator >48 hours, acute renal failure (requiring dialysis), bleeding/transfusions, graft/prosthesis/flap failure, septic shock, sepsis, and organ space surgical site infection), within 30 days of a lower extremity bypass (LEB) in patients age 16 and older.

Percentage of patients presenting with AJCC Stage Group 0, I, II, or III disease, who undergo a needle biopsy to establish diagnosis of breast cancer.

Percentage of female patients, age = 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the breast, had breast conserving surgery and was administered radiation therapy within 1 year (365 days) of diagnosis

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