Facility/Agency

Time of first contact in the ED to the time when the patient sees qualified medical personnel for patient evaluation and management.

Percentage of heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

Percentage of residents with a valid target assessment and one of the following inclusion criteria: 1.Impaired in mobility or transfer on the target assessment
2. Comatose on the target assessment
3. Suffer malnutrition on the target assessment who have pressure ulcers

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 who had an increase in the number of pressure ulcers

Percentage of patients discharged during October, November, December, January, or February with pneumonia, age 50 and older, who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated

Percent of nursing home/ skilled nursing facility residents given the influenza vaccination during the flu season.

Percentage of pneumonia patients 18 years of age and older who receive their first dose of antibiotics within 6 hours after arrival at the hospital

Percent of patients leaving without being seen by a qualified medical personnel.

Percentage of residents with a valid target assessment and not qualifying as high risk who frequently lose control of their bowel or bladder