Process

Median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

The percentage of adults 19 years of age and older who are up-to-date on Advisory Committee on Immunization Practice (ACIP) recommended routine vaccines for influenza, tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap), zoster and pneumococcal.

Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period

Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

This measure identifies patients with diabetes mellitus taking insulin that had evidence of self-monitoring blood glucose testing in last 12 reported months.

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months.

This measure identifies adults with migraines who are frequently taking acute (abortive) medications and are also taking a prophylactic medication for migraine control.

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formulation for preventing progression of AMD