Process

Percentage of patients, aged 18 years and older, for whom percutaneous coronary intervention (PCI) is performed with comprehensive documentation for the procedure that includes, at a minimum, the following elements: priority (acute coronary syndrome, urgent, elective, emergency/salvage); presence and severity of angina symptoms; use of antianginal medical therapies within two weeks prior to the procedure, if any; presence, results, and timing of non-invasive stress test, fractional flow reserve (FFR), or intravascular ultrasound (IVUS), if performed; and significance of angiographic stenosi

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.

The proportion of in-center hemodialysis, home hemodialysis, and peritoneal dialysis patients who have documentation of receiving a new post-dialysis weight prescription from a nephrologist in the reporting month, irrespective of whether or not a change in post dialysis weight prescription was made.

Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivilant such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for first OR second generation cephalosporin for antimicrobial prophylaxis

Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time.

Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required)

Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time