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Measure Index

The National Quality Measures Clearinghouse™ (NQMC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, provides a Measure Index, a complete list of measure summaries available through the NQMC Web site. The listing is organized alphabetically, by measure developer and/or submitter name (measure developers and submitters include both organizations and individuals).

The NQMC Web site is updated weekly. The NQMC Update Service notifies you via e-mail when new features and measures become available at the NQMC Web site. To receive e-mail notifications, subscribe to the NQMC Update Service.

The National Quality Measures Clearinghouse™ currently contains 1836 individual measure summaries.

Accreditation Association for Ambulatory Health Care Institute for Quality Improvement(2)

Intra-procedure colonoscopy complication rate: percentage of patients who developed one or more intra-procedure complications.

Patient understanding of colonoscopy procedure: percentage of patients answering "yes" to the post-procedure telephone interview question "Did you understand why the procedure was being done and what was going to happen?".

Accreditation Association for Ambulatory Health Care Institute for Quality Improvement, Performance Measurement Initiative, Colonoscopy Work Group(2)

Intra-procedure colonoscopy complication rate: percentage of patients who developed one or more intra-procedure complications.

Patient understanding of colonoscopy procedure: percentage of patients answering "yes" to the post-procedure telephone interview question "Did you understand why the procedure was being done and what was going to happen?".

Agency for Healthcare Research and Quality(172)

Abdominal aortic aneurysm (AAA) repair: mortality rate.

Abdominal aortic aneurysm (AAA) repair: volume.

Accidental puncture or laceration (area-level): rate per 100,000 population. [NQMC Update Pending]

Accidental puncture or laceration (provider-level): rate per 1,000 discharges. [NQMC Update Pending]

Acute myocardial infarction (AMI): mortality rate, without transfer cases.

Acute myocardial infarction (AMI): mortality rate.

Acute stroke: mortality rate.

Adult asthma: hospital admission rate.

Asthma admission rate (area level): rate per 100,000 population.

Bacterial pneumonia: hospital admission rate.

Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.

Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.

Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.

Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.

Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.

Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.

Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.

Birth trauma -- injury to neonate: rate per 1,000 liveborn births.

Carotid endarterectomy (CEA): mortality rate.

Carotid endarterectomy (CEA): volume.

Cholecystitis/cholelithiasis: laparoscopic cholecystectomy rate.

Chronic obstructive pulmonary disease (COPD): hospital admission rate.

Complications of anesthesia: rate per 1,000 surgery discharges with an operating room procedure.

Congestive heart failure (CHF): hospital admission rate.

Congestive heart failure (CHF): mortality rate.

Coronary artery bypass graft (CABG): volume.

Coronary artery disease: angina without procedure hospital admission rate.

Coronary artery disease: bilateral cardiac catheterization rate.

Coronary artery disease: coronary artery bypass graft (CABG) area rate.

Coronary artery disease: coronary artery bypass graft (CABG) mortality rate.

Coronary artery disease: percutaneous transluminal coronary angioplasty (PTCA) area rate.

Craniotomy: mortality rate.

Death among surgical inpatients with serious treatable complications: deaths per 1,000 discharges.

Death in low-mortality DRGs: in-hospital deaths per 1,000 discharges.

Decubitus ulcer: rate per 1,000 discharges.

Decubitus ulcer: rate per 1,000 eligible admissions.

Dehydration: hospital admission rate.

Diabetes mellitus: hospital admission rate for long-term complications.

Diabetes mellitus: hospital admission rate for short-term complications.

Diabetes mellitus: hospital admission rate for uncontrolled diabetes.

Diabetes mellitus: lower-extremity amputation rate.

Diabetes short-term complications admission rate (area level): rate per 100,000 population.

Esophageal cancer: esophageal resection mortality rate.

Esophageal resection: volume.

Gastroenteritis admission rate (area level): rate per 100,000 population.

Gastrointestinal (GI) hemorrhage: mortality rate.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had in getting needed care.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had with their health plan customer service, information, and paperwork.

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.

Health plan members' experiences: percentage of adult health plan members who reported how often the medical office staff was courteous, respectful and helpful.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors or other health providers communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had in getting needed care for their child.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with health plan customer service for their children.

Health plan members' experiences: percentage of parents of health plan members who reported how often the medical office staff was courteous, respectful, and helpful.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children get care quickly.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children's doctors or other health providers communicated well.

Health plan members' experiences: percentage of parents of health plan members who reported their experiences with family centered care regarding their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported they had assistance in coordinating care and services for their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.

Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.

Health plan members' satisfaction with care: adult health plan members ratings of the care they received from all doctors and other health providers.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' ratings of their personal health provider.

Health plan members' satisfaction with care: adult health plan members' ratings of their specialist.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.

Health plan members' satisfaction with care: parents' ratings of their children's care.

Health plan members' satisfaction with care: parents' ratings of their children's health plan.

Health plan members' satisfaction with care: parents' ratings of their children's personal health provider.

Health plan members' satisfaction with care: parents' ratings of their children's specialist.

Hip fracture: mortality rate.

Hip osteoarthrosis: hip replacement mortality rate.

Hospital inpatients' experiences: adult inpatients' ratings of this hospital.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean and the area around their room was quiet at night.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.

Hypertension: hospital admission rate.

Hysterectomy: hysterectomy area rate.

Iatrogenic pneumothorax (area-level): rate per 100,000 population. [NQMC Update Pending]

Iatrogenic pneumothorax (provider-level): rate per 1,000 discharges. [NQMC Update Pending]

Iatrogenic pneumothorax in neonates at risk: rate per 1,000 eligible admissions.

Iatrogenic pneumothorax in non-neonates: rate per 1,000 eligible admissions.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.

Incidental appendectomy: incidental appendectomy among the elderly rate.

Laminectomy or spinal fusion: laminectomy or spinal fusion area rate.

Low birth weight: rate of infants with low birth weight.

Maternity care: Cesarean delivery rate.

Maternity care: primary Cesarean delivery rate.

Maternity care: vaginal birth after Cesarean (VBAC) rate, all.

Maternity care: vaginal birth after Cesarean (VBAC) rate, uncomplicated.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 Cesarean deliveries.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 instrument-assisted vaginal deliveries.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 vaginal deliveries without instrument assistance.

Pancreatic cancer: pancreatic resection mortality rate.

Pancreatic resection: volume.

Patients' experiences: percentage of adult primary care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult primary care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of adult specialty care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.

Patients' satisfaction with care: adult primary care patient's overall rating of their doctor.

Patients' satisfaction with care: adult specialty care patient's overall rating of their doctor.

Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.

Pediatric heart surgery mortality: number of in-hospital deaths in patients undergoing surgery for congenital heart disease per 1,000 patients.

Pediatric heart surgery: volume.

Percutaneous transluminal coronary angioplasty (PTCA): mortality rate.

Percutaneous transluminal coronary angioplasty (PTCA): volume.

Perforated appendix admission rate (area level): number of patients admitted for perforated appendix per 100 admissions for appendicitis within an area.

Perforated appendix: hospital admission rate.

Pneumonia: mortality rate.

Postoperative hemorrhage and hematoma: rate per 1,000 eligible admissions.

Postoperative hemorrhage or hematoma requiring a procedure (area-level): rate per 100,000 population. [NQMC Update Pending]

Postoperative hemorrhage or hematoma requiring a procedure (provider level): rate per 1,000 surgical discharges. [NQMC Update Pending]

Postoperative hip fracture: rate per 1,000 surgical discharges.

Postoperative physiologic and metabolic derangement: rate per 1,000 elective surgical discharges with an operating room procedure.

Postoperative pulmonary embolism or deep vein thrombosis: rate per 1,000 surgical discharges with an operating room procedure.

Postoperative respiratory failure: rate per 1,000 elective surgical discharges with an operating room procedure.

Postoperative respiratory failure: rate per 1,000 eligible admissions.

Postoperative sepsis: rate per 1,000 elective surgery discharges with an operating room procedure and a length of stay of 4 days or more.

Postoperative sepsis: rate per 1,000 eligible admissions.

Postoperative wound dehiscence (area-level): rate of reclosure of post operative disruption of abdominal wall per 100,000 population. [NQMC Update Pending]

Postoperative wound dehiscence (provider-level): rate of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. [NQMC Update Pending]

Postoperative wound dehiscence: number of abdominopelvic surgery patients with disruption of abdominal wall per 1,000 eligible admissions.

Selected infection due to medical care: rate per 1,000 eligible admissions.

Selected infections due to medical care (area-level): rate per 100,000 population. [NQMC Update Pending]

Selected infections due to medical care (provider-level): rate per 1,000 discharges. [NQMC Update Pending]

Urinary tract infection (UTI) admission rate (area level): rate per 100,000 population.

Urinary tract infection: hospital admission rate.

Ambulatory Surgery Center (ASC) Quality Collaboration(5)

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions experiencing a burn prior to discharge.

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions experiencing a fall within the confines of the ASC.

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant.

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who receive the prophylactic antibiotic on time.

American Academy of Dermatology(4)

Melanoma: percentage of patients with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.

Melanoma: percentage of patients with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.

Melanoma: percentage of patients with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Melanoma: percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.

American Academy of Family Physicians(10)

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.

American Academy of Neurology(9)

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

American Academy of Ophthalmology(11)

Eye care: percentage of patients aged 18 years and older with a diagnosis of cataracts who were assessed for visual functional status during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.

Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.

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

Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.

American Academy of Orthopaedic Surgeons(13)

Osteoarthritis: percentage of patient visits during which an anti-inflammatory agent or analgesic was considered.

Osteoarthritis: percentage of patient visits during which gastrointestinal (GI) prophylaxis was considered.

Osteoarthritis: percentage of patient visits during which therapeutic exercise for the knee (therapeutic exercise instructed or physical therapy prescribed) was considered.

Osteoarthritis: percentage of patient visits with assessment for function and pain.

Osteoarthritis: percentage of patient visits with assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications.

Osteoarthritis: percentage of patients for whom a physical examination of the involved joint was performed during the initial visit.

Osteoarthritis: percentage of patients on prescribed or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) who were assessed for gastrointestinal (GI)/renal risk factors.

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Foundation(8)

Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.

Otitis media with effusion (OME): percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed/recommended either antihistamines or decongestants.

American Academy of Pediatrics(4)

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.

American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association(15)

Cardiac rehabilitation: percentage of cardiac rehabilitation program(s) in the healthcare system that meet the specified performance measure criteria for communication with healthcare providers.

Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the health system that meet this specified performance measure criteria for monitoring response to therapy and documenting program effectiveness.

Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the healthcare system that meet specified structure-based performance measure criteria.

Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the healthcare system that meet the specified performance measure criteria for assessment of risk for adverse cardiovascular events.

Cardiac rehabilitation: percentage of eligible inpatients with a qualifying event/diagnosis who have been referred to an outpatient cardiac rehabilitation program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made.

Cardiac rehabilitation: percentage of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the previous 12 months, who have been referred to an outpatient cardiac rehabilitation program.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for adherence to preventive medications.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for assessment of exercise capacity.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for assessment of weight management.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for blood pressure control.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for depression.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for diabetes mellitus or impaired fasting glucose.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for lipid control.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for physical activity habits.

Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for tobacco use.

American Association of Clinical Endocrinologists(6)

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

American College of Cardiology(26)

Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.

Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.

Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.

Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.

Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.

Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.

Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.

Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.

Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.

Hypertension: percentage of patient visits with blood pressure measurement recorded.

American College of Emergency Physicians(9)

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.

Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.

Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.

Emergency medicine: percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.

American College of Radiology(17)

Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.

Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.

Radiology: percentage of final reports for screening mammograms that are classified "probably benign".

Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.

Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

American College of Rheumatology(10)

Gout: percentage of patients with gout receiving an initial prescription for allopurinol and have significant renal impairment whose initial daily allopurinol dose is less than 300 mg per day.

Gout: percentage of patients with gout started on urate-lowering therapy who have either a history of nephrolithiasis or significant renal insufficiency who are started on a xanthine oxidase inhibitor as the initial urate-lowering medication rather than a uricosuric agent.

Gout: percentage of patients with hyperuricemia and gouty arthritis who are offered treatment with a urate-lowering drug.

Gout: percentage of patients with tophaceous gout who are given an initial prescription for a urate-lowering medication and lack both significant renal impairment and peptic ulcer disease who had a prophylactic anti-inflammatory agent given concomitantly.

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

American College of Surgeons(6)

Perioperative care: 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.

Perioperative care: percentage of non-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 24 hours of surgical end time.

Perioperative care: percentage of patients 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 24 hours after surgery end time.

Perioperative care: 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 cefazolin or cefuroxime for antimicrobial prophylaxis.

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

Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

American Gastroenterological Association Institute(5)

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.

American Geriatrics Society(9)

Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

Geriatrics: 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.

Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.

American Heart Association(26)

Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.

Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.

Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.

Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.

Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.

Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.

Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.

Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.

Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.

Hypertension: percentage of patient visits with blood pressure measurement recorded.

American Medical Association on behalf of the AAFP, AAOS, AACE, American College of Rheumatology, The Endocrine Society, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(6)

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

American Medical Association on behalf of the American Academy of Dermatology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(4)

Melanoma: percentage of patients with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.

Melanoma: percentage of patients with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.

Melanoma: percentage of patients with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Melanoma: percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.

American Medical Association on behalf of the American Academy of Neurology, American College of Radiology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(9)

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

American Medical Association on behalf of the American Academy of Ophthalmology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(11)

Eye care: percentage of patients aged 18 years and older with a diagnosis of cataracts who were assessed for visual functional status during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.

Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.

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

Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.

American Medical Association on behalf of the American Academy of Orthopaedic Surgeons and Physician Consortium for Performance Improvement®(7)

Osteoarthritis: percentage of patient visits during which an anti-inflammatory agent or analgesic was considered.

Osteoarthritis: percentage of patient visits during which gastrointestinal (GI) prophylaxis was considered.

Osteoarthritis: percentage of patient visits during which therapeutic exercise for the knee (therapeutic exercise instructed or physical therapy prescribed) was considered.

Osteoarthritis: percentage of patient visits with assessment for function and pain.

Osteoarthritis: percentage of patient visits with assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications.

Osteoarthritis: percentage of patients for whom a physical examination of the involved joint was performed during the initial visit.

Osteoarthritis: percentage of patients on prescribed or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) who were assessed for gastrointestinal (GI)/renal risk factors.

American Medical Association on behalf of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Foundation and Physician Consortium for Performance Improvement®(8)

Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.

Otitis media with effusion (OME): percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed/recommended either antihistamines or decongestants.

American Medical Association on behalf of the American Academy of Pediatrics, American Academy of Family Physicians, and Physician Consortium for Performance Improvement®(4)

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.

American Medical Association on behalf of the American College of Cardiology, American Heart Association, and Physician Consortium for Performance Improvement®(26)

Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.

Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.

Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.

Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.

Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.

Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.

Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.

Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.

Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.

Hypertension: percentage of patient visits with blood pressure measurement recorded.

American Medical Association on behalf of the American College of Emergency Physicians, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(9)

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.

Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.

Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.

Emergency medicine: percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.

American Medical Association on behalf of the American College of Radiology, tPhysician Consortium for Performance Improvement®, and National Committee for Quality Assurance(8)

Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.

Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.

Radiology: percentage of final reports for screening mammograms that are classified "probably benign".

Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.

Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.

American Medical Association on behalf of the American College of Surgeons, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(6)

Perioperative care: 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.

Perioperative care: percentage of non-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 24 hours of surgical end time.

Perioperative care: percentage of patients 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 24 hours after surgery end time.

Perioperative care: 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 cefazolin or cefuroxime for antimicrobial prophylaxis.

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

Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

American Medical Association on behalf of the American Gastroenterological Association Institute and Physician Consortium for Performance Improvement®(5)

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.

American Medical Association on behalf of the American Geriatrics Society, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(9)

Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

Geriatrics: 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.

Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.

American Medical Association on behalf of the American Psychiatric Association, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(3)

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.

American Medical Association on behalf of the American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, and Physician Consortium for Performance Improvement®(10)

Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.

Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.

Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.

Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.

American Medical Association on behalf of the American Society of Anesthesiologists and Physician Consortium for Performance Improvement®(3)

Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees).

Anesthesiology and critical care: percentage of patients who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique followed.

Anesthesiology and critical care: percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

American Medical Association on behalf of the American Society of Hematology and Physician Consortium for Performance Improvement®(4)

Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.

Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.

American Medical Association on behalf of the American Urological Association and Physician Consortium for Performance Improvement®(6)

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.

Prostate cancer: percentage of patients, regardless of age, with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.

American Medical Association on behalf of the College of American Pathologists and Physician Consortium for Performance Improvement®(2)

Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Pathology: percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

American Medical Association on behalf of the Physician Consortium for Performance Improvement®(39)

Asthma: percentage of patients aged 5 to 40 years diagnosed with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.

Asthma: percentage of patients aged 5 to 40 years with diagnosed asthma who were evaluated during at least one office visit during the reporting year for the frequency (numeric) of daytime and nocturnal asthma symptoms.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for COPD symptoms at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older who had a spirometry evaluation results documented at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and an oxygen saturation less than or equal to 88% or a PaO2 less than or equal to 55 mm Hg who prescribed long term oxygen therapy.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and dyspnea for whom exercise training was recommended.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and FEV1 less than 40% of predicted value who have oxygen saturation assessed at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD identified as smokers who received a smoking cessation intervention at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received a pneumococcus immunization.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received influenza immunization during current flu season.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for pneumococcus immunization status.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were queried about smoking at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were recommended to receive an influenza immunization annually.

Community-acquired bacterial pneumonia: percentage of patients who had a documented rationale for level of care based on severity and safety of home care.

Community-acquired bacterial pneumonia: percentage of patients who received a smoking cessation intervention.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for co-morbid conditions.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for influenza immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for pneumococcus immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were prescribed an appropriate empiric antibiotic.

Community-acquired bacterial pneumonia: percentage of patients who were queried about smoking.

Community-acquired bacterial pneumonia: percentage of patients with a chest x-ray performed.

Community-acquired bacterial pneumonia: percentage of patients with hydration status assessed.

Community-acquired bacterial pneumonia: percentage of patients with mental status assessed.

Community-acquired bacterial pneumonia: percentage of patients with oxygen saturation assessed.

Community-acquired bacterial pneumonia: percentage of patients with vital signs recorded.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who receive therapy appropriate to their classification during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who were initially treated with antidepressant medication who had the antidepressant medication discontinued who were continued on antidepressant medication for a minimum of 16 weeks following remission of symptoms during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD whose severity of depressive disorder was assessed during the visit in which the new diagnosis or recurrent episode was identified during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD, who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified.

Prenatal care: percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation.

Prenatal care: percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit.

Preventive care and screening: percentage of female patients who had a mammogram performed during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients identified as tobacco users who received cessation intervention during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients screened for colorectal cancer during the one-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who received an influenza immunization during the one-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who were queried about and screened for problem drinking during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who were queried about tobacco use one or more times during the two-year measurement period. [NQMC Update Pending]

American Medical Association on behalf of the Renal Physicians Association and Physician Consortium for Performance Improvement®(12)

Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February).

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period.

Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V greater than or equal to 1.2 OR patients have a Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD who are receiving dialysis have a Hgb greater than or equal to 11g/dL OR have a Hgb less than 11g/dL with a documented plan of care for anemia.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the flu season (September through February).

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula OR patients who are referred for an AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis with a permanent catheter who are referred for evaluation for AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times during the 12 month reporting period.

American Medical Directors Association(65)

Heart failure: average time for a patient's ineffective treatment to be modified.

Heart failure: average time taken to respond to a patient's adverse drug reaction.

Heart failure: percentage of patients monitored for adverse drug reactions.

Heart failure: percentage of patients referred to cardiology/hospice/palliative care (after several ineffective modifications and based on patient's advance directive).

Heart failure: percentage of patients where heart failure is diagnosed urgently or emergently (i.e., not on admission or at periodic assessment).

Heart failure: percentage of patients with documentation that appropriate lab monitoring has been ordered.

Heart failure: percentage of patients with documented assessment for heart failure risk factors.

Heart failure: percentage of patients with documented assessment for imaging studies.

Heart failure: percentage of patients with documented assessment for reversible causes of heart failure.

Heart failure: percentage of patients with documented assessment for reversible etiology workup.

Heart failure: percentage of patients with documented assessment for signs, symptoms, and heart failure risk factors at admission.

Heart failure: percentage of patients with documented consideration of angiotensin-converting enzyme (ACE) inhibitor treatment.

Heart failure: percentage of patients with documented consideration of beta-blocker treatment.

Heart failure: percentage of patients with documented discussions regarding advance directives and/or adherence to the directive.

Heart failure: percentage of patients with documented periodic assessment for peripheral edema and other heart failure risk factors.

Heart failure: percentage of patients with documented periodic monitoring of heart failure symptoms (lung sounds, edema, decreased activity).

Heart failure: percentage of patients with heart failure on angiotensin-converting enzyme (ACE) inhibitor.

Heart failure: percentage of patients with heart failure on beta-blocker.

Heart failure: percentage of patients with heart failure on diuretic therapy for at least 6 months with electrolyte measures within normal ranges.

Heart failure: percentage of patients with heart failure on diuretic therapy who had electrolyte monitoring within the past 2 months.

Heart failure: percentage of patients with heart failure prescribed a low-sodium diet in the past 6 months.

Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with patient's advance care directive.

Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with severity of heart failure.

Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with type of ventricular dysfunction.

Heart failure: percentage of patients with heart failure readmitted for acute episode of heart failure.

Heart failure: percentage of patients with heart failure receiving nonpharmacologic treatment, such as diet intervention and fluid restriction.

Heart failure: percentage of patients with heart failure sent to emergency room (ER) for acute exacerbation.

Heart failure: percentage of patients with heart failure weighed as per physician's orders.

Heart failure: percentage of patients with heart failure weighed daily.

Heart failure: percentage of patients with heart failure with documented assessment of treatment effectiveness.

Heart failure: percentage of patients with heart failure with fluid volume overload prescribed a loop diuretic.

Heart failure: percentage of patients with medical record documentation for characterization of ventricular dysfunction as systolic or diastolic.

Heart failure: percentage of patients with medical record documentation indicating communication of signs and symptoms of heart failure by direct care team to physician/nurse practitioner/physician assistant.

Pain management in the long-term care setting: percentage of patients prescribed narcotics for pain with appropriate bowel management program in place.

Pain management in the long-term care setting: percentage of patients receiving physical complementary treatments.

Pain management in the long-term care setting: percentage of patients receiving physical exam to assess for causes of pain.

Pain management in the long-term care setting: percentage of patients with adverse drug reactions (ADRs) to pain medications.

Pain management in the long-term care setting: percentage of patients with appropriate treatment for pain.

Pain management in the long-term care setting: percentage of patients with cognitive and language problems receiving targeted pain assessment.

Pain management in the long-term care setting: percentage of patients with controlled adverse drug reactions (ADRs) to pain medications.

Pain management in the long-term care setting: percentage of patients with documented absence of pain symptoms after treatment.

Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool at each quarterly review.

Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool at each reported change of condition requiring minimum data set (MDS) notation.

Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool on admission.

Pain management in the long-term care setting: percentage of patients with documented care plan for acute or chronic pain.

Pain management in the long-term care setting: percentage of patients with documented cause of pain symptoms.

Pain management in the long-term care setting: percentage of patients with documented complete assessment of pain covering all pertinent components of pain.

Pain management in the long-term care setting: percentage of patients with documented medication regimen with evidence of titration/adjustment in accordance with World Health Organization (WHO) step ladder.

Pain management in the long-term care setting: percentage of patients with documented reasons for no medical work-up.

Pain management in the long-term care setting: percentage of patients with documented reduction of pain symptoms.

Pain management in the long-term care setting: percentage of patients with orders for not recommended drugs.

Pain management in the long-term care setting: percentage of patients with periodic documented assessment by nursing staff of effectiveness of pain management.

Pain management in the long-term care setting: percentage of patients with periodic documented assessment of effectiveness of pain management by medical doctor (MD).

Pressure ulcers: percentage of patients in facility admitted with a pressure ulcer.

Pressure ulcers: percentage of patients in facility who develop pressure ulcers while in the facility.

Pressure ulcers: percentage of patients with a pressure ulcer or pressure ulcer risk with documented periodic assessment for specific risk factors.

Pressure ulcers: percentage of patients with clinically significant complications.

Pressure ulcers: percentage of patients with documented assessment of pressure ulcer using a formal wound staging classification.

Pressure ulcers: percentage of patients with documented assessment of risks for possible pressure ulcer development.

Pressure ulcers: percentage of patients with documented assessment of skin for breakdown.

Pressure ulcers: percentage of patients with pressure ulcers that heal.

Pressure ulcers: percentage of patients with pressure ulcers with documented treatment plan for pressure reduction approaches.

Pressure ulcers: percentage of patients with pressure ulcers with documented treatment plans citing identified risk factors and co-morbid conditions.

Pressure ulcers: percentage of patients with pressure ulcers with necrotic tissue or slough with documented treatment plan for wound debridement.

Pressure ulcers: percentage of patients with pressure ulcers with periodic documentation on status of the characteristics of wound (e.g., size, depth, color, induration, odor, discharge).

American Physical Therapy Association(1)

Physical functional status: mean change score in patients' mobility following physical therapy intervention as assessed using the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) Instrument.

American Podiatric Medical Association(3)

Diabetes mellitus: percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a lower extremity neurological exam performed at least once within 12 months.

Diabetes mellitus: percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing during one or more office visits within 12 months.

Diabetes mellitus: percentage of patients aged 50 years and older with a diagnosis of diabetes mellitus that had an Ankle Brachial Index (ABI) measurement performed during one or more office visits within 12 months.

American Psychiatric Association(3)

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.

American Society for Therapeutic Radiology and Oncology(10)

Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.

Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.

Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.

Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.

American Society of Anesthesiologists(3)

Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees).

Anesthesiology and critical care: percentage of patients who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique followed.

Anesthesiology and critical care: percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

American Society of Clinical Oncology(10)

Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.

Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.

Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.

Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.

American Society of Hematology(4)

Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.

Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.

American Urological Association(6)

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.

Prostate cancer: percentage of patients, regardless of age, with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.

Arthritis Foundation(51)

Acetaminophen use: percentage of patients prescribed acetaminophen who have risk factors for liver disease AND the percentage of patients treated with high-dose (greater than or equal to 4 gm/day) acetaminophen who are advised of the associated risk of liver toxicity.

Cyclooxygenase 2 (COX-2)-selective non-steroidal anti-inflammatory drug (NSAID) use: percentage of patients treated with a COX-2-selective NSAID who are taking low-dose aspirin daily and have risk factors for GI bleeding who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Low-dose aspirin use: percentage of patients treated with a low-dose aspirin daily who have 2 or more risk factors for GI bleeding who are treated concomitantly with either misoprostol or proton pump inhibitor (PPI).

Low-dose aspirin: percentage of patients prescribed low-dose aspirin (less than or equal to 325 mg/day) who are advised of the associated GI bleeding risks.

Non-selective non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with a non-selective NSAID who have risk factors for GI bleeding and who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who are NOT treated with a low-dose aspirin, have risk factors for GI bleeding and are prescribed an NSAID who receive either a non-selective NSAID plus a gastroprotective agent (proton pump inhibitor [PPI] or misoprostol) or a COX-2-selective NSAID.

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who take coumadin and are prescribed an NSAID who receive either a cyclooxygenase 2 (COX-2)-selective NSAID or a nonacetylated salicylate.

Non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients prescribed an NSAID (non selective or selective) who are advised of the associated GI bleeding and renal risks with the GI risks documented.

Osteoarthritis: percentage of overweight patients (as defined by body mass index of greater than or equal to 27 kg/m2) who are advised to lose weight annually to prevent incident knee or hip osteoarthritis.

Osteoarthritis: percentage of patients beginning drug treatment for "joint pain," "arthritis," or "arthralgia" for whom there is documentation that the affected joint was examined.

Osteoarthritis: percentage of patients with a diagnosis of osteoarthritis and reporting difficulties with non-ambulatory activities of daily living whose functional ability with problem tasks are assessed for need of non-ambulatory assistive devices to aid with problem tasks.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip and reporting difficulty walking to accomplish activities of daily living for greater than 3 months whose walking ability is assessed for need of ambulatory assistive devices.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who are prescribed an exercise program.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who receive or who are recommended patient education.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual functional assessment.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual pain assessment.

Osteoarthritis: percentage of patients with hip or knee osteoarthritis and worsening complaints accompanied by a progressive decrease in activities and no previous radiographs during the preceding 3 months for whom a knee or hip radiograph is performed within 3 months.

Osteoarthritis: percentage of patients with osteoarthritis for whom oral pharmacologic therapy is changed from acetaminophen to a different oral agent with evidence that they have had a trial of maximum-dose acetaminophen (suitable for age and comorbidities).

Osteoarthritis: percentage of patients with osteoarthritis pain of mild or moderate severity for whom acetaminophen is the first drug used for initial nonnarcotic pharmacologic therapy to aid with problem tasks.

Osteoarthritis: percentage of patients with severe symptomatic osteoarthritis of the knee or hip who have failed to respond to nonpharmacologic and pharmacologic therapy who are referred to an orthopedic surgeon.

Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who are overweight (as defined by body mass index of greater than or equal to 27 kg/m2) and who are advised to lose weight to reduce symptoms of osteoarthritis.

Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who have been overweight (as defined by body mass index of greater than or equal to 27 kg/m2) for more than 3 years who are referred to a weight loss program.

Rheumatoid arthritis: percentage of female patients of childbearing age who are newly started on any of the following disease-modifying antirheumatic drugs (DMARDs): methotrexate, cyclophosphamide, azathioprine, sulfasalazine, chlorambucil, D-penicillamine, hydroxychloroquine, gold, etanercept, infliximab, leflunomide for whom a discussion with the patient about the teratogenic risks of these drugs and about contraception is documented.

Rheumatoid arthritis: percentage of patients being treated with methotrexate (MTX) who have elevations in serum transaminase levels above two times the upper range of normal for the laboratory two or more times over a three month period for whom non-steroidal anti-inflammatory drug (NSAID) or MTX dose reduction or discontinuation is documented within one month of the second abnormal laboratory result.

Rheumatoid arthritis: percentage of patients being treated with methotrexate for whom folate supplementation is given.

Rheumatoid arthritis: percentage of patients in the third trimester of pregnancy for whom non-steroidal anti-inflammatory drugs (NSAIDs) (selective and non-selective) and aspirin are not used.

Rheumatoid arthritis: percentage of patients newly prescribed acetaminophen for whom the risk versus benefits of this drug are discussed.

Rheumatoid arthritis: percentage of patients newly prescribed any of the following drugs: non-steroidal anti-inflammatory drugs (NSAIDs) (selective or non-selective), disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, or narcotics for whom a discussion with the patient about the risks versus benefits of the chosen therapy is documented.

Rheumatoid arthritis: percentage of patients on immunosuppressive therapy for whom there is evidence that the following vaccines have been given: influenza (annually), pneumococcal, meningococcal, haemophilus B, hepatitis B, and tetanus.

Rheumatoid arthritis: percentage of patients receiving greater than or equal to 10 mg per day of prednisone (or equivalent) for greater than six months with no documentation of worsening disease for whom there is documentation at some point during the treatment course that a steroid taper was attempted or a disease-modifying antirheumatic drug (DMARD) dose was increased.

Rheumatoid arthritis: percentage of patients receiving immunosuppressants and/or steroid therapy (greater than 10 mg per day prednisone equivalent for greater than two weeks) for whom live/oral polio, live typhoid, yellow fever, measles, mumps, rubella (MMR), bacille Calmette-Guerin (BCG) vaccine are not used.

Rheumatoid arthritis: percentage of patients referred to a physician for a new diagnosis of rheumatoid arthritis who are seen by the physician within 3 months.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis (RA) for whom baseline x-rays of the hands or feet are performed within 3 months of the initial diagnosis and every 3 years.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis for whom each of the following are documented within 3 months of diagnosis and at appropriate time intervals thereafter: a joint examination of three or more joint areas, functional status, disease activity (presence/absence of synovitis), acute phase reactant (defined by erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) and pain (by visual analog scale [VAS] or other mechanism).

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties performing tasks involving use of their hands and wrists either because of stiffness or pain for whom functional ability with their hands and wrists is assessed for need of hand or wrist splints (orthoses).

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties with activities of daily living either because of stiffness or pain for whom functional ability with the compliant tasks is assessed for need of assistive devices to aid with compliant tasks.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulty with walking either because of stiffness, pain or instability for whom walking ability is assessed for need for ambulatory assistive devices including a cane, insoles, and orthotics.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis, no contraindications to exercise and who are physically and mentally able to exercise for whom a directed or supervised muscle strengthening or aerobic exercise program has been prescribed at least once and reviewed at least once per year.

Rheumatoid arthritis: percentage of patients with an established diagnosis of rheumatoid arthritis (RA) whose RA is evaluated by a physician at least annually.

Rheumatoid arthritis: percentage of patients with an established diagnosis of sero-positive rheumatoid arthritis (RA), or RA and synovitis or RA and radiographic erosions who are treated with a disease-modifying antirheumatic drug (DMARD) unless contraindication to DMARD is documented.

Rheumatoid arthritis: percentage of patients with established treatment with a disease-modifying antirheumatic drug (DMARD) or glucocorticoids for whom monitoring for drug toxicity is performed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis and osteoporosis treated with oral or parenteral steroids for whom antiresorptive therapy is prescribed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis started on prednisone greater than or equal to 10 mgs daily, (or other steroid equivalent) and who continue on prednisone for more than three months for whom 1,500 mg calcium and 400 international units (IUs) per day of Vitamin D are prescribed and antiresorptive therapy is discussed with the patient.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are being treated with a disease-modifying antirheumatic drug (DMARD) and report worsening of symptoms over a six-month period of time and have evidence of active disease (synovitis) for whom one of the following are done: dose or route of DMARD administration is changed, DMARD is changed, an additional DMARD is added, or dose of glucocorticoids is started or increased.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are newly prescribed a disease-modifying antirheumatic drug (DMARD) for whom appropriate baseline studies are documented within an appropriate period of time from the original prescription.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have joint pain, joint instability, or tendon rupture affecting the upper extremity or the foot or ankle, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to a surgeon is offered unless contraindication to surgery is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have severe pain of the hips or knees, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to an orthopedic surgeon is offered unless contraindication to surgery is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have surgery requiring general anesthesia for whom there is management or documentation of the risk of atlanto-axial instability.

Rheumatoid arthritis: percentage of pregnant patients for whom methotrexate and leflunomide are not used.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for developing renal insufficiency for whom serum creatinine is assessed at baseline and at least once in the first year following initiation of therapy.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for GI bleeding for whom a complete blood count is performed at baseline and during the first year after initiating therapy.

Australian Council on Healthcare Standards(319)

Access and exit block to the ICU: percentage of appropriate patients referred to an intensive care unit, who are not admitted to the unit because of inadequate resources, during the 6 month time period.

Access and exit block to the ICU: percentage of elective surgical cases deferred or cancelled due to the lack of ICU/HDU bed, during the 6 month time period.

Access and exit block to the ICU: percentage of patients discharged from the intensive care unit (ICU) between 6pm and 6am, during the 6 month time period.

Access and exit block to the ICU: percentage of patients who were transferred to another facility/area/ICU due to unavailability of an ICU bed, during the 6 month time period.

Access and exit block to the ICU: percentage of patients whose discharge from the intensive care unit (ICU) was delayed more than 12 hours, during the 6 month time period.

Access block: percentage of mental health or critical care patients who waited greater than 4 hours in the emergency department (ED) after the time of decision to admit them, during the 6 month time period.

Access block: percentage of patients who were admitted or planned for admission but discharged from the emergency department (ED) without reaching an inpatient bed, transferred to another hospital for admission, or died in the ED whose total ED time exceeded 8 hours, during the 6 month time period.

Acute myocardial infarction (AMI): percentage of patients with an AMI requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the emergency department, as their primary treatment, during the 6 month time period.

Acute myocardial infarction (AMI): percentage of patients with an AMI who receive PTCA as their primary treatment and have balloon inflation within 1 hour of presentation to the emergency department, during the 6 month time period.

Anatomical pathology: percentage of validated large biopsy results with a turnaround time (collected to validated time) less than 96 hours, during the 1 to 2 week time period.

Anatomical pathology: percentage of validated large biopsy results with a turnaround time (received to validated time) less than 92 hours, during the 1 to 2 week time period.

Anatomical pathology: percentage of validated small biopsy results with a turnaround time (collected to validated time) less than 48 hours, during the 1 to 2 week time period.

Anatomical pathology: percentage of validated small biopsy results with a turnaround time (received to validated time) less than 44 hours, during the 1 to 2 week time period.

Antibiotic prophylaxis: percentage of patients who undergo hysterectomy who receive antibiotic prophylaxis prior to surgery, during the 6 month time period.

Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period, excluding same day admissions.

Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period.

Blood transfusion: percentage of adverse transfusion events related to a blood transfusion episode, during the 6 month time period.

Blood transfusion: percentage of red blood cell (RBC) transfusion episodes when the HB reading is 100g/L or more, during the 6 month time period.

Blood transfusion: percentage of transfusion episodes where informed patient consent was not documented, during the 6 month time period.

Cancellation of booked procedures: percentage of patients booked into a day procedure facility who fail to arrive, during the 6 month time period.

Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to a pre-existing medical condition, during the 6 month time period.

Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to administrative/organisational reasons, during the 6 month time period.

Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to an acute medical condition, during the 6 month time period.

Cardiology: percentage of inpatients undergoing coronary artery bypass grafts within 24 hours of percutaneous transluminal coronary angioplasty (PCTA) (with or without stenting) in the same admission, during the 6 month time period.

Cardiology: percentage of patients with acute myocardial infarction (AMI) requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the hospital, during the 6 month time period.

Cardiology: percentage of vessels in which percutaneous transluminal coronary angioplasty (PTCA) (with or without stenting) is undertaken where primary success, as defined, is achieved, during the 6 month time period.

Cardiothoracic surgery: percentage of elective patients who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.

Cardiothoracic surgery: percentage of patients aged 71 years or greater who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.

Cardiothoracic surgery: percentage of patients who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.

Care planning: percentage of carers involved in developing care plans, during the 6 month time period.

Care planning: percentage of consumers with current completed care plans (including consumer involvement and signature) in the file, during the 6 month time period.

Cataract surgery: percentage of patients having a discharge intention of 1 day who had an overnight admission following cataract surgery, during the 6 month time period.

Cataract surgery: percentage of patients having a readmission within 28 days of the discharge following cataract surgery, due to endophthalmitis in the operated eye, during the 6 month time period.

Cataract surgery: percentage of patients having an anterior vitrectomy at the time of cataract surgery, during the 6 month time period.

Cataract surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following cataract surgery, during the 6 month time period.

Central line-associated blood stream infection (CLAB) rate: percentage of paediatric intensive care unit (ICU)-associated centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of haematology unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of haematology unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of oncology unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of oncology unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of outpatient intravenous therapy (OPIV) unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of outpatient intravenous therapy (OPIV) unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.

Central line-associated blood stream infection (CLAB): percentage of paediatric intensive care unit (ICU)-associated peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.

Central line-utilisation ratio (CLUR): number of centrally-inserted (CI) central line-days per patient-days in adult intensive care unit (ICU), during the 6 month time period.

Central line-utilisation ratio (CLUR): number of centrally-inserted (CI) central line-days per patient-days in paediatric intensive care unit (ICU), during the 6 month time period.

Central line-utilisation ratio (CLUR): number of peripherally-inserted (PI) central line-days per patient-days in adult intensive care unit (ICU), during the 6 month time period.

Central line-utilisation ratio (CLUR): number of peripherally-inserted (PI) central line-days per patient-days in paediatric intensive care unit (ICU), during the 6 month time period.

Chemical pathology: percentage of serum/plasma potassium validated report results for ED (or requests specified as urgent) with a turnaround time (received to validated time) less than 60 minutes, during the 2 to 4 week time period.

Colonoscopy: percentage of incomplete colonoscopies performed, during the 6 month time period.

Colonoscopy: percentage of patients treated for possible perforation NOT related to polypectomy, during the 6 month time period.

Colonoscopy: percentage of patients treated for possible perforation who have had a polypectomy performed, during the 6 month time period.

Colonoscopy: percentage of patients who have bleeding, during the 6 month time period.

Complications of sedation: percentage of patients who have an endoscopy procedure involving sedation who are transferred or admitted for an overnight stay as a result of aspiration, during the 6 month time period.

Day of surgery admissions: percentage of elective surgery patients admitted to the organisation on the day of surgery, during the 6 month time period.

Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have an unplanned extension to the time between entry into the post-anaesthesia care unit to the meeting of hospital/day surgery discharge criteria, during the time period under study.

Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have received a pre-anaesthesia assessment before the day of day surgery, during the time period under study.

Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients whose procedure is cancelled on the day of surgery for anaesthetic reasons other than an acute medical condition, during the time period under study.

Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients with unplanned overnight admissions for anaesthetic reasons, during the time period under study.

Dermatological consult: percentage of patients who receive a dermatological consult within 24 hours, greater or equal to 1 day and less than 2 days, greater or equal to 2 days and less than 5 working days, or longer than one week after the primary contact time to assessment visit, during the 6 month time period.

Endocrinology: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, whose medical record shows at least 4 blood glucose measurements on the first post-operative day, during the 6 month time period.

Endocrinology: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, with a recorded blood glucose level less than 4 mmol/L in the post-operative period, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and endoscopic therapy, who subsequently have an operation, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and have a gastroscopy within 24 hours of admission, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and subsequently die, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, and have an operation, during the same admission, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, for which there is documented evidence that a member of the surgical staff has been notified of their condition, during the 6 month time period.

Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, who are discharged with a specific diagnosis that explains the cause of bleeding, during the 6 month time period.

Gastroscopy: percentage of patients treated for possible perforation related to oesophageal dilatation, during the 6 month time period.

Gastroscopy: percentage of patients undergoing gastroscopies (without dilations or polypectomies) who were treated for possible perforation secondary to instrument related causes, during the 6 month time period.

Gastroscopy: percentage of patients undergoing upper gastrointestinal tract polypectomies treated for possible perforation related to polypectomy, during the 6 month time period.

General surgery: percentage of patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention, during the 6 month time period.

Geriatric medicine: percentage of patients admitted to geriatric medicine or geriatric rehabilitation unit for whom there is documented assessment of mental function on admission or during admission when more appropriate, during the 6 month time period.

Geriatric medicine: percentage of patients admitted to geriatric medicine or geriatric rehabilitation unit for whom there is documented assessment of physical function on admission and at least once more during the inpatient stay, during the 6 month time period.

Glaucoma surgery: percentage of patients having a readmission within 28 days of discharge following glaucoma surgery, due to endophthalmitis in the operated eye, during the 6 month time period.

Glaucoma surgery: percentage of patients with a total length of stay (LOS) greater than 3 days following glaucoma surgery, during the 6 month time period.

Glaucoma surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following glaucoma surgery, during the 6 month time period.

Haematology: percentage of Coag validated report results from ED with a turnaround time (collected to validated time) less than 60 minutes, during the 2 to 4 week time period.

Haematology: percentage of Coag validated report results from ED with a turnaround time (received to validated time) less than 40 minutes, during the 2 to 4 week time period.

Haematology: percentage of haemoglobin validated report results from ED with a turnaround time (collected to validated time) less than 60 minutes, during the 2 to 4 week time period.

Haematology: percentage of haemoglobin validated report results from ED with a turnaround time (received to validated time) less than 40 minutes, during the 2 to 4 week time period.

Haemodialysis-associated blood stream infection: percentage of AV-fistula access-associated blood stream infections, during the 6 month time period.

Haemodialysis-associated blood stream infection: percentage of centrally inserted cuffed line access-associated blood stream infections, during the 6 month time period.

Haemodialysis-associated blood stream infection: percentage of centrally inserted non-cuffed line access-associated blood stream infections, during the 6 month time period.

Haemodialysis-associated blood stream infection: percentage of native vessel graft access-associated blood stream infections, during the 6 month time period.

Haemodialysis-associated blood stream infection: percentage of synthetic graft access-associated blood stream infections, during the 6 month time period.

Healthcare-associated MRSA: percentage of intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a non-sterile site, during the 6 month time period.

Healthcare-associated MRSA: percentage of intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a sterile site, during the 6 month time period.

Healthcare-associated MRSA: percentage of non-intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a non-sterile site, during the 6 month time period.

Healthcare-associated MRSA: percentage of non-intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) inpatient healthcare-associated infections in a sterile site, during the 6 month time period.

Hospital in the home: percentage of patients having 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.

Hospital in the home: percentage of patients having more than 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.

Hospital in the home: percentage of patients making 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.

Hospital in the home: percentage of patients making more than 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.

Injury to a major viscus: percentage of patients suffering injury to a major viscus with repair, during a gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Intensive care patient treatment: percentage of patients receiving thromboembolism prophylaxis treatment within 24 hours of admission to the intensive care unit (ICU), during the 6 month time period.

Intra-operative period: percentage of patients receiving a blood transfusion in accordance with National Health and Medical Research Council (NH & MRC) guidelines during a surgical procedure with an anaesthetist in attendance, during the time period under study.

Intra-operative period: percentage of patients undergoing a procedure with an anaesthetist in attendance, who have documented evidence of intra-operative cardiac dysrhythmia/arrest, during the time period under study.

Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where the anaesthesia records substantially complies with the Australian and New Zealand College of Anaesthetists (ANZCA) requirements for the anaesthetic record, during the time period under study.

Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where there is an assistant to an anaesthetist, during the time period under study.

Laparoscopic management of an ectopic pregnancy: percentage of patients having laparoscopic management following an ectopic pregnancy, during the 6 month time period.

Laparoscopic surgery: percentage of patients receiving a bladder injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Laparoscopic surgery: percentage of patients receiving a ureter injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Laparoscopic surgery: percentage of patients receiving an injury to a major viscus with repair, during a laparoscopic gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have read acute pain protocols, during the time period under study.

Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have received education regarding acute pain management, during the time period under study.

Management of acute pain: percentage of patients having neuraxial, or plexus block analgesic technique, demonstrating neurological dysfunction three months post-procedure secondary to neuraxial technique or plexus block.

Management of acute pain: percentage of patients receiving acute pain management developing severe hypotension, requiring an alteration to or change of analgesic technique, during acute pain management, during the time period under study.

Management of acute pain: percentage of patients receiving acute pain management developing severe respiratory depression requiring naloxone administration during acute pain management, during the time period under study.

Management of acute pain: percentage of patients receiving acute pain management who are satisfied with their current pain relief, during the time period under study.

Management of acute pain: percentage of patients receiving acute pain management with analgesia adequate to allow acute rehabilitation (e.g., effective cough, mobilisation), during the time period under study.

Management of acute pain: percentage of patients receiving acute pain management with pain intensity scores regularly recorded by nursing staff, during the time period under study.

Management of acute pain: percentage of patients receiving neuraxial blockade as part of their acute pain management who develop an epidural abscess or epidural haematoma following neuraxial blockade, during the time period under study.

Management of acute pain: percentage of patients reporting nausea and vomiting whilst receiving prescribed antiemetic treatment when nausea and vomiting are present, during acute pain management, during the time period under study.

Mental health community: percentage of consumers or nominated carers 3 or more face-to-face contacts within a 7 day period.

Mental health community: percentage of consumers or nominated carers with greater than 24 treatment days over a three month period.

Mental health community: percentage of consumers who were admitted to the hospital for psychiatric reasons (by that service) once or more in the first year of treatment.

Mental health community: percentage of registered consumers seen face-to-face by the community service, during the 6 month time period.

Mental health inpatient: percentage of inpatient separations having seclusion, during the 6 month time period.

Mental health inpatient: percentage of inpatient separations with a diagnosis on hospital discharge, which is recorded in the medical record, during the 6 month time period.

Mental health inpatient: percentage of inpatient separations with an individual care plan, which is constructed and regularly reviewed with the consumer, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least 1 episode of seclusion, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least 2 episodes of seclusion, in an admission or in a 1 month period of an extended admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least one episode of physical restraint, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion for more than 4 hours in 1 episode, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion who experience major complications while in seclusion, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion who were not reviewed by sight, by a medical practitioner or nurse on at least a half-hourly basis, during the 6 month time period.

Mental health inpatient: percentage of inpatients in an acute unit with a length of stay greater than 30 days, during the 6 month time period.

Mental health inpatient: percentage of inpatients on 3 or more psychotropic medications from 1 sub-group category specified, at the time of discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a discharge summary or letter, at the time of discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a final discharge summary recorded in the medical record within 2 weeks of hospital discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a multidisciplinary review recorded every 3 months, during the 6 month time period.

Mental health inpatient: percentage of inpatients with a complete documented physical examination within 48 hours of admission, during the 6 month time period.

Mental health inpatient: percentage of patients allocated a diagnosis within 24 hours of admission, during the 6 month time period.

Mental health inpatient: percentage of patients experiencing major medical complications while undergoing electro convulsive therapy (ECT), during the 6 month time period.

Mental health inpatient: percentage of patients undergoing more than 12 treatments of electro convulsive therapy (ECT), during the 6 month time period.

Mental health inpatient: percentage of voluntary inpatient admissions, during the 6 month time period.

Microbiology: percentage of validated CSF results from ED for microscopy (+/- gram stain) with a turnaround time (collected to validated time) less than 60 minutes, during the 1 to 2 month time period.

Microbiology: percentage of validated CSF results from ED with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who die as a result of an adverse reaction, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who experience a cerebral hemorrhage, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who experience abnormal bleeding, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient with an international normalized ratio (INR)/prothrombin reading greater than 5, during the 6 month time period.

Monitoring of warfarin: percentage of patients on hospital initiated warfarin who receive written drug information on discharge, during the 6 month time period.

Monitoring of warfarin: percentage of patients with an international normalized ratio (INR) result above the therapeutic range who have had their dosage reviewed prior to the next warfarin administration, during the 6 month time period.

Morbidity of radiological procedures: percentage of patients experiencing iodinated contrast extravasation requiring medical review during an IV contrast enhanced CT procedure, during the 6 month period.

Morbidity of radiological procedures: percentage of patients undergoing percutaneous transpleural biopsy of the lung or mediastinum, for whom there is documented evidence of pneumothorax and/or haemothorax requiring intervention following the procedure, during the 6 month period.

Morbidity of radiological procedures: percentage of peripheral embolic complications during angioplasty of the arteries in upper or lower limbs, during the 6 month period.

Morbidity of radiological procedures: percentage of puncture site complications during or following angiography, during the 6 month period.

Neonatal infections: percentage of babies of birth weight less than 1000 grams admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.

Neonatal infections: percentage of babies of greater than or equal to 1000 grams birth weight, admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.

Neonatal infections: percentage of live babies born at the reporting hospital who develop blood stream and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.

Neonatal infections: percentage of live babies of greater than or equal to 37 weeks estimated gestational age at birth (GA) born at the reporting hospital who develop a blood and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.

Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of greater than or equal to 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.

Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of less than 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.

Nephrology: percentage of inpatients having a renal biopsy who subsequently develop macroscopic haematuria in any of their voided urine specimens with 24 hours of the procedure, during the 6 month time period.

Neurology: percentage of inpatients separated from hospital with a discharge diagnosis of stoke that had a documented CT scan, during the 6 month time period.

Neurosurgery: percentage of patients having a neurosurgical infection in hospital, excluding superficial wound infections, requiring nothing more than a single short course of antibiotics, during the 6 month time period.

Neurosurgery: percentage of patients with a new neurological deficit following a neurosurgery procedure, during the 6 month time period.

Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures in the labour ward for whom there is documented evidence of informed consent for labour ward epidural/spinal analgesia, during the time period under study.

Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures who experience a post-dural puncture headache, during the time period under study.

Obstetric anaesthesia care: percentage of patients requiring immediate lower segment Caesarean section (LSCS) who deliver within 30 minutes of request for immediate LSCS, during the time period under study.

Obstetric anaesthesia care: percentage of patients undergoing lower segment Caesarean section (LSCS) who receive a general anaesthetic for LSCS, during the time period under study.

Obstetrics: percentage of deliveries with birth weight less than 2750g at 40 weeks gestation or beyond.

Obstetrics: percentage of high risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis.

Obstetrics: percentage of inborn term babies transferred/admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality.

Obstetrics: percentage of selected primipara sustaining a perineal tear and NO episiotomy.

Obstetrics: percentage of selected primipara undergoing caesarean section.

Obstetrics: percentage of selected primipara undergoing episiotomy and NO perineal tear while giving birth vaginally.

Obstetrics: percentage of selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally.

Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for fourth degree tear.

Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for third degree tear.

Obstetrics: percentage of selected primipara who have a spontaneous vaginal birth.

Obstetrics: percentage of selected primipara who undergo an instrumental vaginal birth.

Obstetrics: percentage of selected primipara who undergo induction of labour.

Obstetrics: percentage of selected primipara with an intact perineum.

Obstetrics: percentage of serious adverse events that are addressed within a peer review process.

Obstetrics: percentage of term babies born with an Apgar score of less than 7 at five minutes post delivery.

Obstetrics: percentage of women delivering vaginally following a previous primary caesarean section.

Obstetrics: percentage of women having a general anaesthetic for caesarean section.

Obstetrics: percentage of women who give birth vaginally who require a blood transfusion during the same admission.

Obstetrics: percentage of women who receive an appropriate prophylactic antibiotic at the time of caesarean section.

Obstetrics: percentage of women who undergo a caesarean section who require a blood transfusion during the same admission.

Occupational exposure: percentage of reported non-parenteral exposures sustained by staff, during the 6 month time period.

Occupational exposure: percentage of reported parenteral exposures sustained by staff, during the 6 month time period.

Oncology: percentage of pre-menopausal patients with stage II carcinoma of the breast for whom there is documented evidence of treatment, or intention to treat, with polychemotherapy, during the 6 month time period.

Oral health - children: percentage of deciduous teeth extracted (for pathological reasons) within 6 months following pulpotomy treatment, during the time period under study.

Oral health - children: percentage of teeth requiring re-treatment (restoration, endodontic or extraction, but not including Pit & Fissure Sealants) within 24 months of the initial fissure sealant treatment.

Oral health - children: percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment.

Oral health: percentage of attendances for complications within 7 days of routine extraction, during the time period under study.

Oral health: percentage of attendances for complications within 7 days of surgical extraction, during the time period under study.

Oral health: percentage of completed courses of endodontic treatment on the same tooth within 6 months of initial treatment, during the time period under study.

Oral health: percentage of new patients aged 65 years and over who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged 65 years and over who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged under 18 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged under 18 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 18 to 24 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 18 to 24 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 25 to 64 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 25 to 64 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of patients with completed and updated medical history, during the time period under study.

Oral health: percentage of patients with completed charting at initial assessment for general course of care, during the time period under study.

Oral health: percentage of radiographs (bite-wing) that meet all of the 6 criteria (as outlined), during the time period under study.

Oral health: percentage of same denture type (full or partial) and same arch remade within 12 months, during the time period under study.

Oral health: percentage of teeth extracted within 12 months of completing a course of endodontic treatment, during the time period under study.

Oral health: percentage of teeth retreated between 1 and 6 months of completing a course of endodontic treatment, during the time period under study.

Oral health: percentage of teeth retreated within 6 months of an episode of restorative treatment, during the time period under study.

Orthopaedic surgery: percentage of patients undergoing primary total hip joint replacement (THJR) having a postoperative in hospital infection, during the 6 month time period.

Otolaryngology: percentage of patients who have a significant reactionary haemorrhage following tonsillectomy, during the 6 month time period.

Paediatric immunisation: percentage of infants admitted as inpatients for whom there is documented current immunisation status, during the 6 month time period.

Paediatric immunisation: percentage of infants admitted as inpatients with not up to date immunisation status for whom there is documented evidence that they were either given catch up immunisations; or that such immunisation was planned, during the 6 month time period.

Paediatric intensive care unit (ICU) access: percentage of appropriate patients referred to an ICU, who are not admitted to the unit because of inadequate resources, during the 6 month time period.

Paediatric intensive care unit (ICU) access: percentage of elective surgical cases deferred or cancelled due to lack of ICU/HDU bed, during the 6 month time period.

Paediatric intensive care unit (ICU) access: percentage of patients discharged from the ICU between 6PM and 6AM, during the 6 month time period.

Paediatric intensive care unit (ICU) access: percentage of patients who were transferred to another facility/area/ICU due to unavailability of an ICU bed, during the 6 month time period.

Paediatric intensive care unit (ICU) access: percentage of patients whose discharge from the ICU was delayed more than 12 hours, during the 6 month time period.

Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, but significant other intra-abdominal pathology, during the 6 month time period.

Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, during the 6 month time period.

Paediatric surgery: percentage of patients having a pyloromyotomy in which mucosal perforation occurs and is detected at the time of the operation or later, during the 6 month time period.

Patient deaths: percentage of patient deaths addressed within a clinical audit process, during the 6 month time period.

Patient recovery period: percentage of patients undergoing a procedure who are reviewed by an anaesthetist to manage severe pain, not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for a temperature recorded in the recovery period of less than 35 degrees Celsius, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for cardiovascular reasons, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for post-operative nausea and vomiting not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for respiratory or cardiac arrest, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to relieve respiratory distress, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to treat inadequate reversal of neuro-muscular blockade, in the recovery period, during the time period under study.

Patient recovery period: percentage of patients undergoing a procedure with an anaesthetist in attendance, who have an unplanned post-anaesthesia care unit (PACU) stay longer than two hours, during the time period under study.

Phototherapy: percentage of patients receiving broad band UVB phototherapy, during the 6 month time period.

Phototherapy: percentage of patients receiving narrow band UVB phototherapy, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy for eczema, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy for other dermatoses, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy for psoriasis, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where a protocol for dose and documentation of side effects were used, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the explanation of phototherapy and side effects, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the total UVB dose administered, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of treatment outcome at the conclusion of the phototherapy course, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of written informed consent, during the 6 month time period.

Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence that contraindications were considered, during the 6 month time period.

Plastic surgery: percentage of completely excised malignant skin tumors, during the 6 month time period.

Post-operative period: percentage of patients receiving anaesthesia care having an unplanned admission to an intensive care or high dependency unit within 24 hours of a procedure with an anesthetist in attendance, during the time period under study.

Post-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, for which there is documented evidence of a post anaesthesia review, or other process as determined by the anaesthetic department, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care in whom it is judged that there has been adequate peri-operative management of current medications (e.g., diabetic medication), during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have consent for the administration of anaesthesia or sedation documented in the patient chart, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received information about the risks associated with the anaesthesia technique, as documented in the patient chart, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written information on the anaesthesia technique, as documented in the patient chart, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written, verbal, or visual information on the anaesthesia technique, as documented in the patient chart, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care who, according to the relevant protocol, qualify for preoperative ECG recording who have undergone an ECG tracing according to the departmental or established protocols, during the time period under study.

Pre-anaesthesia period: percentage of patients receiving anaesthesia care with a history of post operative nausea and vomiting (PONV) to whom a prophylactic anti-emetic has been administered, during the time period under study.

Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by an anaesthetist, during the time period under study.

Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by the anaesthetist who will be responsible for their anaesthesia care, during the time period under study.

Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who are seen by an anaesthetist before entering the operating theatre suite, anaesthetic room, or procedure room, during the time period under study.

Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who receive an anaesthesia assessment by an anaesthetist, of an appropriate duration, during the time period under study.

Radiation oncology: percentage of curative megavoltage radiotherapy courses provided, where CT planning was utilised, during the 6 month time period.

Radiation oncology: percentage of patients receiving megavoltage radiotherapy using multi-leaf collimators (MLCs), during the 6 month time period.

Radiation oncology: percentage of patients receiving radiotherapy, who have a letter on file to the referring doctor and general practitioner, regarding the current radiotherapy course, during 1 week in May or November.

Radiation oncology: percentage of patients waiting more than 14 days from the date 'ready for care', to the date of commencing radiotherapy, during 1 week in May or November.

Radiation oncology: percentage of patients who had radiotherapy for breast conservation (pT 1-3, any nodal staging, M0), during the 6 month time period, who had complete follow-up.

Radiation oncology: percentage of patients who had radiotherapy for glottic cancer (T1-2 N0 M0), during the 6 month time period, who had complete follow-up.

Radiation oncology: percentage of patients who have informed consent recorded in the medical record before receiving radiotherapy, during 1 week in May or November.

Radiation oncology: percentage of patients who receive curative chemoradiotherapy for squamous cell carcinoma (SCC) of the cervix in the definitive or the post-operative setting, during the 6 month time period.

Radiation oncology: percentage of patients with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, hypopharynx and larynx who wait longer than 6 weeks from their definitive surgery to commencing their radiotherapy, during the 6 month time period.

Refractive surgery: percentage of patients having a complication (medical or surgical) within 28 days following excimer laser surgery, during the 6 month time period.

Refractive surgery: percentage of patients having a discharge intention of 1 day, who had an overnight admission following refractive surgery, during the 6 month time period.

Refractive surgery: percentage of patients having a readmission within 28 days of discharge, following refractive surgery, due to endophthalmitis in the operated eye, during the 6 month time period.

Refractive surgery: percentage of patients having an anterior vitrectomy at the time of refractive surgery, during the 6 month time period.

Refractive surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following refractive surgery, during the 6 month time period.

Rehabilitation medicine: percentage of inpatients for whom there is documented evidence of a functional assessment within 72 hours prior to cessation of an inpatient rehabilitation program, during the 6 month time period.

Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is a documented established multidisciplinary rehabilitation plan within 7 days of patient admission, during the 6 month time period.

Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is documented evidence of a functional assessment within 72 hours of patient admission, during the 6 month time period.

Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and been discharged to their pre-episode form of accommodation, or a form of accommodation that allows great independence, during the 6 month time period.

Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and for whom there is documented evidence of functional gain, during the 6 month time period.

Rehabilitation medicine: percentage of separations for which there is an appropriate discharge plan for a patient, during the 6 month time period.

Report availability: percentage of reports on radiographic examinations not available to the referring doctor within 24 hours of completion, during that 7 day time period.

Retinal detachment surgery: percentage of patients having an unplanned reoperation on the same eye within 28 days, following retinal detachment surgery, during the 6 month time period.

Retinal detachment surgery: percentage of patients with a total length of stay (LOS) greater than 4 days, following retinal detachment surgery, during the 6 month time period.

Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, due to endophthalmitis in the operated eye, during the 6 month time period.

Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, during the 6 month time period.

Skin tumour pathology (biopsy book): percentage of histopathology specimens taken with a skin tumour working diagnosis, during the 6 month time period.

Skin tumour pathology (biopsy book): percentage of patients for whom management lag time was less than 1 working day, greater than or equal to 1 working day and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.

Skin tumour pathology (biopsy book): percentage of patients for whom patient information lag time was less than 1 working day, greater than or equal to 1 working day and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.

Skin tumour pathology (biopsy book): percentage of patients for whom time to review was less than 2 working days, greater than or equal to 2 working days and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in femoral-popliteal bypass procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in the donor incision site) in coronary artery bypass graft (CABG) procedures performed (involving chest and donor incisions), during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in femoral-popliteal bypass procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs)(in the donor incision site) in coronary artery bypass graft (CABG) procedures performed (involving chest and donor incisions), during the 6 month time period.

Surgical site infection: percentage of superficial surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.

Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented evidence of an appropriate discharge plan, during the 6 month time period.

Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity in addition to the initial assessment, which facilitates ongoing inpatient management, during the 6 month time period.

Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity on initial presentation, during the 6 month time period.

Thromboprophylaxis: percentage of high-risk medical patients admitted who receive venous thromboembolism (VTE) prophylaxis, during the 6 month time period.

Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo hysterectomy who receive thromboprophylaxis, during the 6 month time period.

Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo pelvic floor surgery who receive thromboprophylaxis, during the 6 month time period.

Urogynaecology: percentage of patients receiving bladder injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Urogynaecology: percentage of patients receiving injury to major viscus with repair, during a pelvic floor repair procedure subsequently up to 2 weeks post-operatively, during the 6 month time period.

Urogynaecology: percentage of patients receiving ureter injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

Urology: average number of patient days (from the first day after surgery) for all patients having a transurethral resection (TUR) for benign prostatomegaly (excluding patients having other procedures), during the 6 month time period.

Urology: average operating time (minutes) for all patients undergoing a transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.

Urology: percentage of patients having a transurethral resection (TUR) for benign prostatomegaly, who have a blood transfusion (intra-operatively or post-operatively) within the same admission, during the 6 month time period.

Urology: percentage of patients having an unplanned readmission within 28 days of discharge following transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.

Vascular surgery: percentage of patients having a carotid endarterectomy who have a stroke within the same admission, during the 6 month time period.

Vascular surgery: percentage of patients having an elective abdominal aortic aneurysm (AAA) repair, who die within the same admission, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 1 who are attended to immediately, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 2 who are attended to within 10 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 3 who are attended to within 30 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 4 who are attended to within 60 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 5 who are attended to within 120 minutes, during the 6 month time period.

British Medical Association(80)

Asthma: the percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability and reversibility. [NQMC Update Pending]

Asthma: the percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months. [NQMC Update Pending]

Asthma: the percentage of patients with asthma who have had an asthma review in the previous 15 months. [NQMC Update Pending]

Asthma: the practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the previous twelve months. [NQMC Update Pending]

Atrial fibrillation: the percentage of patients with atrial fibrillation diagnosed after 1 April 2006 with electrocardiogram (ECG) or specialist confirmed diagnosis. [NQMC Update Pending]

Atrial fibrillation: the percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy. [NQMC Update Pending]

Atrial fibrillation: the practice can produce a register of patients with atrial fibrillation. [NQMC Update Pending]

Cancer: the percentage of patients with cancer diagnosed from 1 April 2003 with a review by the practice recorded within six months of confirmed diagnosis. [NQMC Update Pending]

Cancer: the practice can produce a register of all cancer patients defined as a 'register of patients with a diagnosis of cancer excluding nonmelanotic skin cancers from 1 April 2003.' [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less. [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register with hypertension who are treated with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded). [NQMC Update Pending]

Chronic kidney disease (CKD): the practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD). [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 15 months. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD with a record of FeV1 in the previous 15 months. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the practice can produce a register of patients with COPD. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an angiotensin-converting enzyme (ACE) inhibitor or Angiotensin II antagonist. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the last 15 months) is 150/90 mm Hg or less. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease with a record in the previous 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Coronary heart disease: the percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment. [NQMC Update Pending]

Coronary heart disease: the practice can produce a register of patients with coronary heart disease. [NQMC Update Pending]

Dementia: the percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months. [NQMC Update Pending]

Dementia: the practice can produce a register of patients diagnosed with dementia. [NQMC Update Pending]

Depression: the percentage of patients with a new diagnosis of depression, recorded between the preceeding 1 April to 31 March, who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care. [NQMC Update Pending]

Depression: the percentage of patients with diabetes and/or coronary heart disease (CHD) for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last blood pressure is 145/85 or less. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 10 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of HbA1c or equivalent in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria). [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of retinal screening in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes whose notes record body mass index (BMI) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II [A2] antagonists). [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of medication review involving the patient and/or carer in the previous 15 months. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the previous 15 months. [NQMC Update Pending]

Epilepsy: the practice can produce a register of patients age 18 years and over receiving drug treatment for epilepsy. [NQMC Update Pending]

Heart failure: the percentage of patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), who can tolerate therapy and for whom there is no contraindication. [NQMC Update Pending]

Heart failure: the percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment. [NQMC Update Pending]

Heart failure: the practice can produce a register of patients with heart failure. [NQMC Update Pending]

Hypertension: the percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less. [NQMC Update Pending]

Hypertension: the percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months. [NQMC Update Pending]

Hypertension: the practice can produce a register of patients with established hypertension. [NQMC Update Pending]

Hypothyroidism: the percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months. [NQMC Update Pending]

Hypothyroidism: the practice can produce a register of patients with hypothyroidism. [NQMC Update Pending]

Learning disabilities: the practice can produce a register or patients with learning disabilities. [NQMC Update Pending]

Mental health: the percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months. [NQMC Update Pending]

Mental health: the percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months. [NQMC Update Pending]

Mental health: the percentage of patients on the mental health register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate. [NQMC Update Pending]

Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance. [NQMC Update Pending]

Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. [NQMC Update Pending]

Mental health: the practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses. [NQMC Update Pending]

Obesity: the practice can produce a register of patients aged 16 and over with a body mass index (BMI) greater than or equal to 30 in the previous 15 months. [NQMC Update Pending]

Palliative care: the practice has a complete register available of all patients in need of palliative care/support. [NQMC Update Pending]

Palliative care: the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. [NQMC Update Pending]

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. [NQMC Update Pending]

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma whose notes record smoking status in the previous 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of new patients with a stroke who have been referred for further investigation. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in previous 15 months) is 150/90 or less. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke whose last measured total cholesterol (measured in previous 15 months) is 5 mmol/l or less. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the practice can produce a register of patients with stroke or TIA. [NQMC Update Pending]

CAHPS Consortium(88)

Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.

Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.

Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.

Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.

Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.

Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.

Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had in getting needed care.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had with their health plan customer service, information, and paperwork.

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.

Health plan members' experiences: percentage of adult health plan members who reported how often the medical office staff was courteous, respectful and helpful.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors or other health providers communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had in getting needed care for their child.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with health plan customer service for their children.

Health plan members' experiences: percentage of parents of health plan members who reported how often the medical office staff was courteous, respectful, and helpful.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children get care quickly.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children's doctors or other health providers communicated well.

Health plan members' experiences: percentage of parents of health plan members who reported their experiences with family centered care regarding their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported they had assistance in coordinating care and services for their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.

Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.

Health plan members' satisfaction with care: adult health plan members ratings of the care they received from all doctors and other health providers.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' ratings of their personal health provider.

Health plan members' satisfaction with care: adult health plan members' ratings of their specialist.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.

Health plan members' satisfaction with care: parents' ratings of their children's care.

Health plan members' satisfaction with care: parents' ratings of their children's health plan.

Health plan members' satisfaction with care: parents' ratings of their children's personal health provider.

Health plan members' satisfaction with care: parents' ratings of their children's specialist.

Hospital inpatients' experiences: adult inpatients' ratings of this hospital.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean and the area around their room was quiet at night.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.

Patients' experiences: percentage of adult primary care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult primary care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of adult specialty care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.

Patients' satisfaction with care: adult primary care patient's overall rating of their doctor.

Patients' satisfaction with care: adult specialty care patient's overall rating of their doctor.

Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.

Canadian Institute for Health Information(3)

Hip fracture: risk adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges. [NQMC Update Pending]

Physician to population ratio: total number of general physicians and family physicians per 100,000 population. [NQMC Update Pending]

Physician to population ratio: total number of specialist physicians per 100,000 population. [NQMC Update Pending]

Center for Health Services Research, University of Colorado, under contract to Centers for Medicare and Medicaid Services(41)

Home health care: percentage of patients discharged to the community.

Home health care: percentage of patients who are confused less often.

Home health care: percentage of patients who get better at bathing.

Home health care: percentage of patients who get better at getting dressed.

Home health care: percentage of patients who get better at getting in and out of bed.

Home health care: percentage of patients who get better at taking their medicines correctly (by mouth).

Home health care: percentage of patients who get better at walking or moving around.

Home health care: percentage of patients who get better getting to and from the toilet.

Home health care: percentage of patients who had to be admitted to the hospital.

Home health care: percentage of patients who have less pain when moving around.

Home health care: percentage of patients who need urgent, unplanned medical care.

Home health care: percentage of patients who stay the same or don't get worse at bathing.

Home health care: percentage of patients whose speech and oral (verbal) expression of language improved.

Home health care: percentage of patients whose speech and oral (verbal) expression of language stabilized.

Home health care: percentage of patients with a decrease in the current number of (observable) surgical wounds.

Home health care: percentage of patients with improvement in ability to do laundry.

Home health care: percentage of patients with improvement in ability to shop.

Home health care: percentage of patients with improvement in anxiety frequency.

Home health care: percentage of patients with improvement in behavioral problem frequency.

Home health care: percentage of patients with improvement in bowel incontinence frequency.

Home health care: percentage of patients with improvement in cognitive functioning.

Home health care: percentage of patients with improvement in dressing lower body.

Home health care: percentage of patients with improvement in dyspnea.

Home health care: percentage of patients with improvement in eating.

Home health care: percentage of patients with improvement in grooming.

Home health care: percentage of patients with improvement in housekeeping.

Home health care: percentage of patients with improvement in light meal preparation.

Home health care: percentage of patients with improvement in status of surgical wounds.

Home health care: percentage of patients with improvement in telephone use.

Home health care: percentage of patients with improvement in urinary incontinence.

Home health care: percentage of patients with improvement in urinary tract infection.

Home health care: percentage of patients with stabilization in ability to do laundry.

Home health care: percentage of patients with stabilization in ability to shop.

Home health care: percentage of patients with stabilization in anxiety frequency.

Home health care: percentage of patients with stabilization in cognitive functioning.

Home health care: percentage of patients with stabilization in grooming.

Home health care: percentage of patients with stabilization in housekeeping.

Home health care: percentage of patients with stabilization in light meal preparation.

Home health care: percentage of patients with stabilization in management of oral medications.

Home health care: percentage of patients with stabilization in telephone use.

Home health care: percentage of patients with stabilization in transferring.

Center for Quality Assessment and Improvement in Mental Health(17)

Bipolar disorder: percentage of patients with Bipolar I Disorder with depressive symptoms and behaviors who have evidence of use of a mood stabilizing or antimanic agent during the first 12 weeks of pharmacotherapy treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their level-of-functioning in response to treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are provided with education and information about their illness and treatment within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms twice within the first 24 weeks of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who receive at least one screening for hyperglycemia within the initial 16 weeks of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who received at least one assessment for hyperlipidemia within the initial 16 week period of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with lithium who have evidence of a lithium serum medication level with 12 weeks of beginning treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder who receive an initial assessment that considers the risk of suicide.

Bipolar disorder: the percentage of patients with bipolar disorder who receive a recommendation for an adjunctive psychosocial intervention, including evidence-based therapies, within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients with bipolar disorder who receive an initial assessment that considers alcohol and chemical substance use.

Bipolar disorder: the percentage of patients with bipolar disorder who were monitored for weight gain during initial 12 week period of treatment.

Bipolar disorder: the percentage of patients with Bipolar I Disorder symptoms and behaviors who received monotherapy with an antidepressant agent during the first 12 weeks of treatment.

Bipolar disorder: the percentage of patients with Bipolar I Disorder with mania/hypomania, mixed or cycling symptoms and behaviors who have evidence of use of pharmacotherapy agent with antimanic properties during the first 12 weeks of treatment.

Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers alcohol and chemical substance use.

Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers the risk of suicide.

Depression: the percentage of patients presenting with depression who were assessed, prior to the initiation of treatment, for the presence of prior or current symptoms and/or behaviors associated with mania or hypomania.

Centers for Education and Research on Therapeutics at the University of Alabama at Birmingham(4)

Gout: percentage of patients with gout receiving an initial prescription for allopurinol and have significant renal impairment whose initial daily allopurinol dose is less than 300 mg per day.

Gout: percentage of patients with gout started on urate-lowering therapy who have either a history of nephrolithiasis or significant renal insufficiency who are started on a xanthine oxidase inhibitor as the initial urate-lowering medication rather than a uricosuric agent.

Gout: percentage of patients with hyperuricemia and gouty arthritis who are offered treatment with a urate-lowering drug.

Gout: percentage of patients with tophaceous gout who are given an initial prescription for a urate-lowering medication and lack both significant renal impairment and peptic ulcer disease who had a prophylactic anti-inflammatory agent given concomitantly.

Centers for Medicare & Medicaid Services(176)

Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: median time from hospital arrival to PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients who expired during hospital stay. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 100 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital arrival. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients with documentation that they or their caregivers were given a written Home Management Plan of Care (HMPC) document. [NQMC Update Pending]

End stage renal disease (ESRD): percentage of adult continuous ambulatory peritoneal dialysis (CAPD) patients for whom the delivered PD dose was a weekly Kt/Vurea of at least 2.0 and a weekly creatinine clearance (CrCl) of at least 60 L/week/1.73 m2 or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period.

End stage renal disease (ESRD): percentage of adult continuous cycling peritoneal dialysis (CCPD) patients for whom the delivered PD dose was a weekly Kt/Vurea of at least 2.1 and a weekly creatinine clearance (CrCl) of at least 63 L/week/1.73 m2 or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) or peritoneal dialysis (PD) patients receiving Epoetin therapy with documented mean hemoglobin (Hgb) of 11-12 g/dL (110-120 g/L) during the study period.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients for whom delivered HD dose was calculated using formal urea kinetic modeling or Daugirdas II during the study period.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients whose average delivered dose of HD was a single-pool Kt/V (spKt/V) greater than or equal to 1.2 during the study period.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation and serum ferritin concentration result every three months.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during a three-month period.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the study months.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with documented monthly adequacy measurements (urea reduction ratio [URR] or single-pool Kt/V [spKt/V]) during the study period.

End stage renal disease (ESRD): percentage of adult hemodialysis patients who were dialyzed through an arterial venous (AV) graft and whose AV graft was routinely surveyed (screened) for the presence of stenosis during the study period.

End stage renal disease (ESRD): percentage of adult nightly intermittent peritoneal dialysis (NIPD) patients for whom the delivered PD dose was a weekly Kt/Vurea of at least 2.2 and a weekly creatinine clearance (CrCl) of at least 66 L/week/1.73 m2 or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period.

End stage renal disease (ESRD): percentage of adult patients who were dialyzed with a chronic catheter continuously for 90 days or longer prior to the last hemodialysis (HD) session during the study period.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during the six-month study period.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least two documented transferrin saturation and serum ferritin concentration results over the six-month study period.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the two-month periods during the six-month study period.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with total solute clearance for urea and creatinine measured at least once in a 6 month time period.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with weekly Kt/Vurea and creatinine clearance (CrCl) calculated in a standard way.

End stage renal disease (ESRD): percentage of incident adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period.

End stage renal disease (ESRD): percentage of prevalent adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had in getting needed care.

Health plan members' experiences: percentage of adult health plan members who reported how much of a problem they had with their health plan customer service, information, and paperwork.

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.

Health plan members' experiences: percentage of adult health plan members who reported how often the medical office staff was courteous, respectful and helpful.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors or other health providers communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had in getting needed care for their child.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported how much of a problem they had with health plan customer service for their children.

Health plan members' experiences: percentage of parents of health plan members who reported how often the medical office staff was courteous, respectful, and helpful.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children get care quickly.

Health plan members' experiences: percentage of parents of health plan members who reported how often their children's doctors or other health providers communicated well.

Health plan members' experiences: percentage of parents of health plan members who reported their experiences with family centered care regarding their children with chronic conditions.

Health plan members' experiences: percentage of parents of health plan members who reported they had assistance in coordinating care and services for their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.

Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.

Health plan members' satisfaction with care: adult health plan members ratings of the care they received from all doctors and other health providers.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' ratings of their personal health provider.

Health plan members' satisfaction with care: adult health plan members' ratings of their specialist.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.

Health plan members' satisfaction with care: parents' ratings of their children's care.

Health plan members' satisfaction with care: parents' ratings of their children's health plan.

Health plan members' satisfaction with care: parents' ratings of their children's personal health provider.

Health plan members' satisfaction with care: parents' ratings of their children's specialist.

Heart failure: percent of 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. [NQMC Update Pending]

Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]

Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Home health care: percentage of patients discharged to the community.

Home health care: percentage of patients who are confused less often.

Home health care: percentage of patients who get better at bathing.

Home health care: percentage of patients who get better at getting dressed.

Home health care: percentage of patients who get better at getting in and out of bed.

Home health care: percentage of patients who get better at taking their medicines correctly (by mouth).

Home health care: percentage of patients who get better at walking or moving around.

Home health care: percentage of patients who get better getting to and from the toilet.

Home health care: percentage of patients who had to be admitted to the hospital.

Home health care: percentage of patients who have less pain when moving around.

Home health care: percentage of patients who need urgent, unplanned medical care.

Home health care: percentage of patients who stay the same or don't get worse at bathing.

Home health care: percentage of patients whose speech and oral (verbal) expression of language improved.

Home health care: percentage of patients whose speech and oral (verbal) expression of language stabilized.

Home health care: percentage of patients with a decrease in the current number of (observable) surgical wounds.

Home health care: percentage of patients with improvement in ability to do laundry.

Home health care: percentage of patients with improvement in ability to shop.

Home health care: percentage of patients with improvement in anxiety frequency.

Home health care: percentage of patients with improvement in behavioral problem frequency.

Home health care: percentage of patients with improvement in bowel incontinence frequency.

Home health care: percentage of patients with improvement in cognitive functioning.

Home health care: percentage of patients with improvement in dressing lower body.

Home health care: percentage of patients with improvement in dyspnea.

Home health care: percentage of patients with improvement in eating.

Home health care: percentage of patients with improvement in grooming.

Home health care: percentage of patients with improvement in housekeeping.

Home health care: percentage of patients with improvement in light meal preparation.

Home health care: percentage of patients with improvement in status of surgical wounds.

Home health care: percentage of patients with improvement in telephone use.

Home health care: percentage of patients with improvement in urinary incontinence.

Home health care: percentage of patients with improvement in urinary tract infection.

Home health care: percentage of patients with stabilization in ability to do laundry.

Home health care: percentage of patients with stabilization in ability to shop.

Home health care: percentage of patients with stabilization in anxiety frequency.

Home health care: percentage of patients with stabilization in cognitive functioning.

Home health care: percentage of patients with stabilization in grooming.

Home health care: percentage of patients with stabilization in housekeeping.

Home health care: percentage of patients with stabilization in light meal preparation.

Home health care: percentage of patients with stabilization in management of oral medications.

Home health care: percentage of patients with stabilization in telephone use.

Home health care: percentage of patients with stabilization in transferring.

Hospital inpatients' experiences: adult inpatients' ratings of this hospital.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.

Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean and the area around their room was quiet at night.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.

Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.

Nursing facility chronic care: percent of eligible and willing long-stay residents given the influenza vaccination during the flu season.

Nursing facility chronic care: percent of eligible and willing long-stay residents who were assessed and given pneumococcal vaccination.

Nursing facility chronic care: percent of high-risk residents who have pressure sores.

Nursing facility chronic care: percent of low-risk residents who have pressure sores.

Nursing facility chronic care: percent of low-risk residents who lose control of their bowels or bladder.

Nursing facility chronic care: percent of residents who have become more depressed or anxious.

Nursing facility chronic care: percent of residents who have moderate to severe pain.

Nursing facility chronic care: percent of residents who have/had a catheter inserted and left in their bladder.

Nursing facility chronic care: percent of residents who lose too much weight.

Nursing facility chronic care: percent of residents who spent most of their time in bed or in a chair during the assessment period.

Nursing facility chronic care: percent of residents who were physically restrained.

Nursing facility chronic care: percent of residents whose ability to move about in and around their room got worse.

Nursing facility chronic care: percent of residents whose need for help with daily activities has increased.

Nursing facility chronic care: percent of residents with a urinary tract infection.

Nursing facility post acute care: percent of eligible and willing short-stay residents given the influenza vaccination during the flu season.

Nursing facility post acute care: percent of eligible and willing short-stay residents who were assessed and given pneumococcal vaccination.

Nursing facility post-acute care: percent of short-stay residents who had moderate to severe pain.

Nursing facility post-acute care: percent of short-stay residents who have pressure sores.

Nursing facility post-acute care: percent of short-stay residents with delirium.

Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. [NQMC Update Pending]

Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. [NQMC Update Pending]

Pneumonia: percent of patients whose initial emergency department blood culture was performed prior to the administration of the first hospital dose of antibiotics. [NQMC Update Pending]

Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Pregnancy and related conditions: percent of live-born neonates who expire before the neonate becomes age 28 days.

Pregnancy and related conditions: percent of patients who have vaginal deliveries with third or fourth degree perineal laceration.

Pregnancy and related conditions: percent of patients with vaginal birth after cesarean section (VBAC).

Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. [NQMC Update Pending]

Surgical care improvement project: percent of colorectal surgery patients with immediate postoperative normothermia. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. [NQMC Update Pending]

Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with appropriate hair removal. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. [NQMC Update Pending]

Centers for Medicare & Medicaid Services/The Joint Commission(31)

Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: median time from hospital arrival to PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital arrival. [NQMC Update Pending]

Heart failure: percent of 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. [NQMC Update Pending]

Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]

Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. [NQMC Update Pending]

Pneumonia: percent of patients whose initial emergency department blood culture was performed prior to the administration of the first hospital dose of antibiotics. [NQMC Update Pending]

Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. [NQMC Update Pending]

Surgical care improvement project: percent of colorectal surgery patients with immediate postoperative normothermia. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. [NQMC Update Pending]

Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with appropriate hair removal. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. [NQMC Update Pending]

Child and Adolescent Health Measurement Initiative(37)

Anticipatory guidance and parental education (AGPE) about development and behavior of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) about injury prevention from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) about the physical care of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of recommended topics discussed by a child's doctor(s) or other health provider(s).

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of topics for which parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose health care provider(s) discussed at least 80% of the recommended AGPE topics.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met on all recommended anticipatory guidance and parental education topics assessed.

Ask about parental concerns (developmental surveillance): proportion of children whose parents were asked by their child's health care provider if they have concerns about their child's learning, development and behavior.

Assessment of psychosocial well-being of parent(s) in the family: average percentage of recommended topics assessed.

Assessment of psychosocial well-being of parent(s) in the family: proportion of children whose parents were assessed for one or more topics related to psychosocial well-being.

Assessment of smoking, substance abuse, safety, and firearms risks in the family by a child's doctor(s) or other health care provider(s): proportion of children whose parents were assessed for one or more risk factors.

Assessment of smoking, substance abuse, safety, and firearms risks in the family: average percentage of recommended topics assessed.

Care coordination (CC): proportion of children needing more than one health care service who received coordinated care.

Communication and experience of care: mean score on seven items asking about helpfulness of office staff, overall rating of care and whether doctor/other providers listen carefully, explain things clearly, respect you, spend enough time.

Effect of care provided on parental confidence: proportion of children whose parents reported care had a positive influence on their confidence in parenting their child and managing their responsibilities.

Family-centered care (FCC): average percentage of recommended aspects of family-centered care regularly received.

Family-centered care (FCC): proportion of children whose parents routinely received all aspects of family-centered care.

Follow-up for children at risk for delays: proportion of children who were determined to be at significant risk for developmental, behavioral, or social delays who received some level of follow-up health care.

Health information: proportion of children whose parents received all health information.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.

Helpfulness of care provided to parents: proportion of children whose parents reported care provided was helpful or very helpful on core aspects of preventive and developmental health care.

Helpfulness of counseling: mean score on six items asking about the helpfulness of counseling among young adults who received counseling on selected topics.

Information about resources for parents in the community: proportion of parents who had their informational needs met.

Information to address parental concerns: proportion of children whose parents had concerns about their child's learning, development and behavior and they received information to address their concerns.

Preventive and developmental health care for young children: average percentage of individual care components (assessed in the Promoting Healthy Development Survey [PHDS]) a child received.

Preventive and developmental health care for young children: proportion of children who received all individual care components measures in the Promoting Healthy Development Survey (PHDS).

Preventive screening and counseling on emotional health and relationship issues: average proportion saying "yes" to six items about whether provider(s) discussed/screened for feeling sad or depressed, school performance, friends, suicide and sexual orientation.

Preventive screening and counseling on risky behaviors: average proportion saying "yes" to ten items about whether provider(s) discussed/screened on smoking, alcohol use, helmet use, drunk driving, chewing tobacco, street drugs, steroid pills, sexual/physical abuse, violence, guns.

Preventive screening and counseling on sexual activity and sexually transmitted diseases (STDs): average proportion saying "yes" to four items about whether provider(s) discussed/screened on birth control, condoms and prevention of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and STDs.

Preventive screening and counseling on weight, healthy diet and exercise: average proportion saying "yes" to three items.

Private and confidential care: average proportion reporting that they had a private and/or confidential visit.

Standardized developmental and behavioral screening: proportion of children whose health care provider administered a parent-completed standardized developmental and behavioral screening tool.

Child Health Corporation of America(1)

Neonatology: percentage of neonates who received each of five specified immunizations.

Chinman, Matthew, Ph.D. (MIRECC); Young, Alexander S., M.D., M.S.H.S. (MIRECC); Sandy Forquer (Comprehensive Neuroscience Inc.); Edward Knight (ValueOptions); Anita Miller (ValueOptions); Melissa Rowe (RAND)(15)

Competency Assessment Instrument (CAI): provider's mean score on the "Client Preferences" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Community Resources" scale.

Competency Assessment Instrument (CAI): Provider's mean score on the "Evidence-based Practice" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Family Education" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Family Involvement" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Goals" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Holistic Approach" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Intensive Case Management" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Medication Management" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Natural Supports" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Rehabilitation" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Skill Advocacy" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Stigma" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Stress" scale.

Competency Assessment Instrument (CAI): Provider's mean score on the "Team Value" scale.

Chinman, Matthew, Ph.D.; Young, Alexander S., M.D., M.S.H.S.; Veterans Administration Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC)(15)

Competency Assessment Instrument (CAI): provider's mean score on the "Client Preferences" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Community Resources" scale.

Competency Assessment Instrument (CAI): Provider's mean score on the "Evidence-based Practice" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Family Education" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Family Involvement" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Goals" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Holistic Approach" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Intensive Case Management" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Medication Management" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Natural Supports" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Rehabilitation" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Skill Advocacy" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Stigma" scale.

Competency Assessment Instrument (CAI): provider's mean score on the "Stress" scale.

Competency Assessment Instrument (CAI): Provider's mean score on the "Team Value" scale.

College of American Pathologists(2)

Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Pathology: percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Eisen, Susan V. PhD(7)

Mental health/substance abuse: mean of patient's change scores on the "Interpersonal Relationships" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Depression/Functioning" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Emotional Lability" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Psychosis" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Self-harm" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Substance Abuse" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' overall change scores on the BASIS-24® survey.

Family Violence Prevention Fund(8)

Domestic violence: percent of adult and adolescent patients assessed who disclosed that they were victims of abuse.

Domestic violence: percent of adult and adolescent patients seen by a provider who were assessed for intimate partner violence (IPV) during the last year.

Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV who were offered information about IPV and referrals.

Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV whose records include prompts for specific follow-up questions about IPV to occur at the patient's next visit.

Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted.

Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified assessments were conducted.

Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified intervention and treatment plans were offered.

Domestic violence: percent of providers of health care services to adult and adolescent patients in the clinical setting who documented that they complied with assessment protocols.

Focus On Therapeutic Outcomes, Inc.(6)

Foot/ankle functional status: mean change score in foot/ankle functional status of patients with foot/ankle impairments receiving physical rehabilitation.

Hip functional status: mean change score in hip functional status of patients with hip impairments receiving physical rehabilitation.

Knee functional status: mean change score in knee functional status of patients with knee impairments receiving physical rehabilitation.

Lumbar functional status: mean change score in lumbar functional status for patients with lumbar impairments receiving physical rehabilitation.

Physical functional health status: mean change score in physical functional health status of patients receiving physical rehabilitation.

Shoulder functional status: mean change score in shoulder functional status with shoulder impairments receiving physical rehabilitation.

Harvard Medical School(17)

Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.

Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.

Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.

Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.

Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.

Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.

Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.

Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.

Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.

Health Resources and Services Administration(42)

Asthma: average number of lost workdays and/or school days in the past 30 days.

Asthma: average number of symptom-free days in the previous two weeks.

Asthma: percent of patients evaluated for environmental triggers other than environmental tobacco smoke (dust mites, cats, dogs, molds/fungi, cockroaches) either by history of exposure and/or by allergy testing.

Asthma: percent of patients older than 5 years with moderate or severe persistent asthma who have established a "personal best" peak flow.

Asthma: percent of patients who have a record of influenza immunization in the past 12 months.

Asthma: percent of patients who have had a visit to an Emergency Department (ED)/Urgent Care office for asthma in the past six months.

Asthma: percent of patients with a documented screening for depression in the past 12 months.

Asthma: percent of patients with a reported exposure to environmental tobacco smoke at last visit.

Asthma: percent of patients with a severity assessment at last contact (visit or phone).

Asthma: percent of patients with documented self-management goals in the last 12 months.

Asthma: percent of patients with persistent asthma at last contact who are on an anti-inflammatory medication.

Depression: percent of clinically significant depression patients who attain a 5 point or greater reduction in Patient Health Questionnaire (PHQ) score within 6 months after their New Episode PHQ.

Depression: percent of clinically significant depression patients who have a documented Current Patient Health Questionnaire (PHQ) reassessment between 4 to 8 weeks after their last New Episode PHQ.

Depression: percent of clinically significant depression patients who have had a documented follow-up 1 to 3 weeks after their last New Episode Patient Health Questionnaire (PHQ).

Depression: percent of clinically significant depression patients who, within one month of last New Episode Patient Health Questionnaire (PHQ), are on an antidepressant and/or in psychotherapy.

Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ) 4 months or longer after the last New Episode PHQ.

Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ).

Depression: percent of clinically significant depression patients with a Patient Health Questionnaire (PHQ) score less than 5, 4 months or longer after their last New Episode PHQ.

Depression: percent of patients with a diagnoses of minor depression, depression not otherwise specified (NOS), or adjustment disorder (New Episode Patient Health Questionnaire [PHQ] less than 10) who are NOT on an antidepressant.

Depression: percent of patients with a diagnosis of depression and a documented Patient Health Questionnaire (PHQ) score within the last 6 months.

Depression: percent of patients with a diagnosis of depression reporting an improvement in function.

Depression: percent of patients with a diagnosis of depression with documented self-management goals set within the last 12 months.

Depression: percent of patients with a diagnosis of major depression or dysthymia who, as of their last visit, are taking an antidepressant.

Depression: percent of patients with diagnosis of major depression or dysthymia who have been on antidepressants for at least 6 months.

Diabetes mellitus: average HbA1c value for diabetic patients in the clinical information system.

Diabetes mellitus: percent of patients 12 to 70 years of age who are not already on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and have had a microalbuminuria screening test in the last 12 months.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for aspirin or other antithrombotic agent.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for statins.

Diabetes mellitus: percent of patients 55 years and older who have a current prescription for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.

Diabetes mellitus: percent of patients who are current smokers (documented in the last 12 months).

Diabetes mellitus: percent of patients who have had a comprehensive foot exam in the past 12 months.

Diabetes mellitus: percent of patients who have had a dilated eye exam in last 12 months.

Diabetes mellitus: percent of patients who have had one pneumococcal vaccination at any time.

Diabetes mellitus: percent of patients who obtained a dental exam in the last 12 months.

Diabetes mellitus: percent of patients who obtained an influenza vaccination in the last 12 months.

Diabetes mellitus: percent of patients whose last documented exercise rate (within the last 12 months) was three times per week for at least 20 minutes.

Diabetes mellitus: percent of patients whose most recent fasting low-density lipoprotein (LDL) was less than 100 (in the last 12 months).

Diabetes mellitus: percent of patients with 2 HbA1c's in the last year (at least 3 months apart).

Diabetes mellitus: percent of patients with a body mass index (BMI) greater than 25 who have lost 10 pounds at any time in the last 12 months.

Diabetes mellitus: percent of patients with a documented screening for depression in the past 12 months.

Diabetes mellitus: percent of patients with blood pressure reading less than 130/80 in the last 12 months.

Diabetes mellitus: percent of patients with documented self-management goals in the last 12 months.

HealthPartners(7)

Cardiovascular disease (CVD): percentage of members with a diagnosis of CVD who have optimally managed modifiable cardiovascular risk factors (LDL cholesterol, blood pressure, daily aspirin use, non-tobacco use).

Cervical cancer screening: percentage of women ages 21 years and older in the measurement year screened in accordance with evidence-based standards.

Coronary artery disease (CAD): percentage of members with CAD who have optimally managed modifiable cardiovascular risk factors (LDL cholesterol, blood pressure control, daily aspirin use, documented non-tobacco use).

Depression: percentage of members ages 18 years and older diagnosed with a new episode of depression, treated with antidepressant medication and optimally managed.

Diabetes mellitus: percentage of members with diabetes (Type I and Type II) who have optimally managed modifiable cardiovascular risk factors (HbA1c, LDL cholesterol, blood pressure control, aspirin use and documented non-tobacco use).

Preventive services: percentage of adult enrolled members ages 19 years and older that are up-to-date for all appropriate preventive services.

Preventive services: percentage of enrolled members ages less than or equal to 18 years who are up-to-date for all appropriate preventive services.

HRSA Health Disparities Collaboratives: Asthma Collaborative(11)

Asthma: average number of lost workdays and/or school days in the past 30 days.

Asthma: average number of symptom-free days in the previous two weeks.

Asthma: percent of patients evaluated for environmental triggers other than environmental tobacco smoke (dust mites, cats, dogs, molds/fungi, cockroaches) either by history of exposure and/or by allergy testing.

Asthma: percent of patients older than 5 years with moderate or severe persistent asthma who have established a "personal best" peak flow.

Asthma: percent of patients who have a record of influenza immunization in the past 12 months.

Asthma: percent of patients who have had a visit to an Emergency Department (ED)/Urgent Care office for asthma in the past six months.

Asthma: percent of patients with a documented screening for depression in the past 12 months.

Asthma: percent of patients with a reported exposure to environmental tobacco smoke at last visit.

Asthma: percent of patients with a severity assessment at last contact (visit or phone).

Asthma: percent of patients with documented self-management goals in the last 12 months.

Asthma: percent of patients with persistent asthma at last contact who are on an anti-inflammatory medication.

HRSA Health Disparities Collaboratives: Depression Collaborative(13)

Depression: percent of clinically significant depression patients who attain a 5 point or greater reduction in Patient Health Questionnaire (PHQ) score within 6 months after their New Episode PHQ.

Depression: percent of clinically significant depression patients who have a documented Current Patient Health Questionnaire (PHQ) reassessment between 4 to 8 weeks after their last New Episode PHQ.

Depression: percent of clinically significant depression patients who have had a documented follow-up 1 to 3 weeks after their last New Episode Patient Health Questionnaire (PHQ).

Depression: percent of clinically significant depression patients who, within one month of last New Episode Patient Health Questionnaire (PHQ), are on an antidepressant and/or in psychotherapy.

Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ) 4 months or longer after the last New Episode PHQ.

Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ).

Depression: percent of clinically significant depression patients with a Patient Health Questionnaire (PHQ) score less than 5, 4 months or longer after their last New Episode PHQ.

Depression: percent of patients with a diagnoses of minor depression, depression not otherwise specified (NOS), or adjustment disorder (New Episode Patient Health Questionnaire [PHQ] less than 10) who are NOT on an antidepressant.

Depression: percent of patients with a diagnosis of depression and a documented Patient Health Questionnaire (PHQ) score within the last 6 months.

Depression: percent of patients with a diagnosis of depression reporting an improvement in function.

Depression: percent of patients with a diagnosis of depression with documented self-management goals set within the last 12 months.

Depression: percent of patients with a diagnosis of major depression or dysthymia who, as of their last visit, are taking an antidepressant.

Depression: percent of patients with diagnosis of major depression or dysthymia who have been on antidepressants for at least 6 months.

HRSA Health Disparities Collaboratives: Diabetes Collaborative(18)

Diabetes mellitus: average HbA1c value for diabetic patients in the clinical information system.

Diabetes mellitus: percent of patients 12 to 70 years of age who are not already on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and have had a microalbuminuria screening test in the last 12 months.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for aspirin or other antithrombotic agent.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for statins.

Diabetes mellitus: percent of patients 55 years and older who have a current prescription for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.

Diabetes mellitus: percent of patients who are current smokers (documented in the last 12 months).

Diabetes mellitus: percent of patients who have had a comprehensive foot exam in the past 12 months.

Diabetes mellitus: percent of patients who have had a dilated eye exam in last 12 months.

Diabetes mellitus: percent of patients who have had one pneumococcal vaccination at any time.

Diabetes mellitus: percent of patients who obtained a dental exam in the last 12 months.

Diabetes mellitus: percent of patients who obtained an influenza vaccination in the last 12 months.

Diabetes mellitus: percent of patients whose last documented exercise rate (within the last 12 months) was three times per week for at least 20 minutes.

Diabetes mellitus: percent of patients whose most recent fasting low-density lipoprotein (LDL) was less than 100 (in the last 12 months).

Diabetes mellitus: percent of patients with 2 HbA1c's in the last year (at least 3 months apart).

Diabetes mellitus: percent of patients with a body mass index (BMI) greater than 25 who have lost 10 pounds at any time in the last 12 months.

Diabetes mellitus: percent of patients with a documented screening for depression in the past 12 months.

Diabetes mellitus: percent of patients with blood pressure reading less than 130/80 in the last 12 months.

Diabetes mellitus: percent of patients with documented self-management goals in the last 12 months.

Inouye, Sharon K. M.D., M.P.H.(1)

Delirium: proportion of patients meeting diagnostic criteria on the Confusion Assessment Method (CAM).

Institute for Clinical Systems Improvement(93)

Adult low back pain: percentage of acute low back pain patients without red flag indicators undergoing anterior-posterior (AP) or lateral (LAT) x-rays. [NQMC Update Pending]

Ankle sprain: percentage of patients with acute ankle sprain for whom documentation of receiving patient education materials is recorded in the medical record.

Ankle sprain: percentage of patients with acute ankle sprain receiving ankle x-rays at clinic within 3 days of the initial injury.

Assessment and management of acute pain: after 48 hours, the percentage of patients who rate pain greater than 4 (on a 10-point scale) or at an unacceptable level to patient.

Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record.

Atrial fibrillation: percentage of patients (without contraindications to anticoagulation) with paroxysmal, persistent, or permanent atrial fibrillation/atrial flutter (A Fib/Flutter) with risk factors for thromboembolism who are on warfarin. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): percentage of patients with COPD whose physician inquired about smoking cessation (if patient a smoker) at every visit.

Colorectal cancer screening: percentage of African American patients age 45 and older who are up-to-date with colorectal cancer screening.

Colorectal cancer screening: percentage of patients age 50 and older who are up-to-date with colorectal cancer screening.

Community-acquired pneumonia (CAP) in adults: percentage of patients with a diagnosis of CAP that had a chest x-ray to confirm diagnosis.

Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication.

Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication.

Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record.

Diagnosis and management of asthma: percentage of patients with asthma with spirometry or peak flow meter reading documented in the medical record at the last visit.

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients diagnosed with ADHD whose medical record contains documentation that the clinician discussed the need for school-based supports and educational service options for children with ADHD.

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients newly diagnosed with ADHD whose medical record contains documentation of DSM-IV or DSM-PC criteria being addressed.

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients treated with medication for the diagnosis of ADHD whose medical record contains documentation of a follow-up visit twice a year.

Diagnosis and management of type 2 diabetes mellitus: frequency of low-density lipoprotein (LDL) cholesterol values in adult patients with type 2 diabetes mellitus by category: less than 100 mg/dL, 100-130 mg/dL, greater than 130 mg/dL, incalculable, untested.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients who have had a screen for A1C, LDL less than 100 mm/dL, blood pressure less than 130/80, who are current documented non-smokers and take daily aspirin.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with A1C measured in the last six months.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with eye exam documented within last 12 months.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with microalbumin tested within last 12 months.

Diagnosis and treatment of adult degenerative joint disease (DJD)/ Osteoarthritis (OA) of the knee: percentage of patients with DJD with documented education in four comprehensive areas: protecting the joint, exercise, pain relief, healthy living habits.

Diagnosis and treatment of adult degenerative joint disease (DJD)/Osteoarthritis (OA) of the knee: percentage of patients diagnosed with DJD with knee x-ray panels that include a standing view of the knee.

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving beta-blockers within 24 hours of arrival and on discharge. [NQMC Update Pending]

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving thrombolytics with a "door-to-drug time" (time from presentation to administration of drug) of less than 30 minutes. [NQMC Update Pending]

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with chest pain symptoms in emergency department (ED) receiving early therapy including intravenous (IV) access, oxygen, nitroglycerin, morphine and a chewable aspirin on arrival. [NQMC Update Pending]

Diagnosis and treatment of headache: percentage migraineurs with treatment plans for mild, moderate, and severe headaches.

Diagnosis and treatment of headache: percentage of migraineurs with documented education.

Diagnosis and treatment of otitis media in children: percentage of caregivers receiving education on the symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media.

Diagnosis and treatment of otitis media in children: percentage of patients with a diagnosis of acute otitis media who were prescribed amoxicillin.

Diagnosis and treatment of respiratory illness in children and adults: percentage of encounters for cold symptoms (phone care and/or office visits) for which there is documentation of home treatment education.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis who had strep screen testing.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than seven days and who receive an antibiotic.

Diagnosis of breast disease: percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7 to 10 days.

Domestic violence: percentage of health care staff trained in initial assessment of problems of domestic violence every twelve months.

Heart failure in adults: percentage of adult heart failure patients to whom (or to their caregivers) written or verbal instructions or educational material are given during the clinic visit, addressing one or more of the following: activity level, diet, medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and met the following (for which they are eligible) at their last clinic visit: prescribed or were taking ACEI/ARB, prescribed or were on beta blocker therapy, non-smoker (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were on beta-blocker therapy within the last 12 months of the clinic visit or who have a contraindication to taking beta-blockers (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were taking an ACEI or ARB within the last 12 months of the clinic visit, or who have contradictions to taking both ACEI or an ARB (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have not used tobacco anytime during the previous year (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have used tobacco anytime during the previous year and who were given smoking cessation advice or counseling at the last clinic visit (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients with documentation that LVS function was evaluated or will be evaluated (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her 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.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have a contraindication to taking beta-blockers, who are prescribed beta-blocker therapy at hospital discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have contraindications to taking both ACEI and ARBs, who are prescribed an ACEI or an ARB at hospital discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have used tobacco anytime during the year prior to hospital arrival and who are given smoking cessation advice or counseling during the hospital stay or at discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge.

Hypertension diagnosis and treatment: percentage of patients who have blood pressure less than 140/90 mmHg at the clinic visit. [NQMC Update Pending]

Hypertension diagnosis and treatment: percentage of patients with hypertension presenting in clinic within the last month for whom patient education about modifiable risk factors has been documented in the medical record. [NQMC Update Pending]

Immunizations: percentage of adolescents who are on time with recommended immunizations (Hep B, Hep A, HPV, MMR, MCV4, Tdap, VZV). [NQMC Update Pending]

Immunizations: percentage of two-year olds who are on time with their primary series of immunizations (DTaP, IPV, MMR, PCV7/PPV23, VZV, Hib, Hep B, Hep A, Rota). [NQMC Update Pending]

Initial management of abnormal cervical cytology (Pap smear) and human papillomavirus (HPV) testing: percentage of adult women diagnosed with initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk HPV type who have follow-up colposcopy within six months of abnormality identified. [NQMC Update Pending]

Lipid management in adults: percentage of patients on a lipid lowering medication who have a fasting lipid panel every 3 to 12 months.

Lipid management in adults: percentage of patients with diagnosed coronary heart disease (CHD) or CHD equivalent who have had a diet evaluation.

Major depression in adults in primary care: percentage of patients who commit suicide at any time while under depression management with a primary care physician.

Major depression in adults in primary care: percentage of patients who have a depression follow-up contact within three months of initiating treatment.

Major depression in adults in primary care: percentage of patients who have had a response to treatment at six months (+/- 30 days) after initiating treatment i.e., have had a Patient Health Questionnaire (PHQ-9) score decreased by 50% from initial score at six months (+/- 30 days).

Major depression in adults in primary care: percentage of patients who have reached remission at six months (+/- 30 days) after initiating treatment, i.e., have any PHQ-9 score less than five after six months (+/- 30 days).

Major depression in adults in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as Patient Health Questionnaire [PHQ-9]) within three months of initiating treatment.

Major depression in adults in primary care: percentage of patients with a new diagnosis of major depression, with documentation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria within the three months prior to initial diagnosis.

Major depression in adults in primary care: percentage of patients with diabetes with documentation of screening for depression.

Management of labor: percentage of births with amnioinfusion when either of the following is present: thick meconium or repetitive severe variable decelerations or oligohydramnios.

Management of labor: percentage of women in the guideline population who have spontaneous rupture of membranes (SROM) or early amniotomy.

Management of labor: percentage of women in the guideline population with failure to progress diagnosis who have oxytocin.

Management of labor: percentage of women who are assessed for risk status on entry to labor and delivery.

Menopause and hormone therapy (HT): collaborative decision-making and management: the percentage of women in menopause who have had a bone mineral density (BMD) measurement a year after cessation of HT. [NQMC Update Pending]

Palliative care: percentage of adult patients with a progressive, debilitating disease who have a palliative care plan documented in the medical record.

Preoperative evaluation: percentage of patients with a preoperative health history and physical examination completed prior to the day of scheduled procedure.

Prevention and management of obesity (mature adolescents and adults): percentage of patients with a documented Body Mass Index (BMI) equal to or greater than 25 who were given education and counsel for weight loss strategies.

Preventive services for adults: percentage of patients with all Level I preventive services on time according to the guideline delivery schedule. [NQMC Update Pending]

Preventive services for children and adolescents: the percentage of patients who are on time with recommended immunizations. [NQMC Update Pending]

Routine prenatal care: percentage of all identified preterm birth (PTB) modifiable risk factors assessed that receive an intervention.

Routine prenatal care: percentage of pregnant women who report to have received counseling and education by the 28th week visit.

Routine prenatal care: percentage of vaginal birth after cesarean (VBAC) eligible women who receive general education describing risks and benefits of VBAC (e.g., the American College of Obstetricians and Gynecologists pamphlet on VBAC).

Stable coronary artery disease (CAD): percentage of patients with stable CAD who have aspirin use documented in the medical record.

Stable coronary artery disease (CAD): percentage of patients with stable CAD who have had a lipid profile determination at target (less than 100) and measured within the last year.

Tobacco use prevention and cessation for adults and mature adolescents: percentage of patients with documented tobacco use or exposure at the latest visit who also have documentation that their cessation interest was assessed or that they received advice to quit.

Tobacco use prevention and cessation for adults and mature adolescents: percentage of patients' charts that either show that there is no tobacco use/exposure or (if a user) that the current use was documented at the most recent clinician visit.

Tobacco use prevention and cessation for infants, children and adolescents: percentage of patients with documented tobacco use or exposure at the latest visit who also have documentation that their cessation interest was assessed or that they received advice to quit.

Tobacco use prevention and cessation for infants, children and adolescents: percentage of patients' charts showing either that there is no tobacco use/exposure or (if a user) that the current use was documented at the most recent clinician visit.

Uncomplicated urinary tract infection in women: percentage of women reporting satisfaction with their management of uncomplicated urinary tract infection (UTI) (patient survey).

Uncomplicated urinary tract infection in women: percentage of women with uncomplicated urinary tract infection (UTI) treated with recommended short course therapy.

Uncomplicated urinary tract infection in women: percentage of women with uncomplicated urinary tract infection (UTI) with a urine culture performed at the initial encounter.

Venous thromboembolism (VTE) prophylaxis: percentage of adult hospitalized patients who are assessed for VTE risk within 24 hours of admission. [NQMC Update Pending]

Venous thromboembolism (VTE) prophylaxis: percentage of hospitalized adult patients who require hospital readmission within 30 days of discharge for conditions related to VTE. [NQMC Update Pending]

Venous thromboembolism (VTE): percentage of adult patients receiving heparin therapy for VTE who have a baseline platelet count before starting heparin, and then a platelet count every other day for at least the first 3 days of therapy.

Venous thromboembolism (VTE): percentage of adult patients suspected of deep vein thrombosis (DVT) who have leg duplex ultrasound with compression performed despite a low clinical pretest probability and a negative D-dimer test.

Venous thromboembolism (VTE): percentage of adult patients treated for VTE who have been assessed for the need for graded compression stockings.

Venous thromboembolism (VTE): percentage of adult patients who have a high clinical pretest probability for pulmonary embolism (PE) who received low molecular weight heparin (LMWH) during evaluation.

Venous thromboembolism (VTE): percentage of low-molecular-weight heparin (LMWH)-eligible patients with deep vein thrombosis (DVT) treated in an outpatient setting.

Venous thromboembolism (VTE): percentage of patients diagnosed with VTE who meet the criteria for low-molecular-weight heparin (LMWH) and for whom LMWH is used.

Joint Commission, The(57)

Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: median time from hospital arrival to PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients receiving PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. [NQMC Update Pending]

Acute myocardial infarction: percent of patients who expired during hospital stay. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 100 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. [NQMC Update Pending]

Acute myocardial infarction: percent of patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital arrival. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization. [NQMC Update Pending]

Children's asthma care: percent of pediatric asthma inpatients with documentation that they or their caregivers were given a written Home Management Plan of Care (HMPC) document. [NQMC Update Pending]

Heart failure: percent of 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. [NQMC Update Pending]

Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]

Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]

Hospital-based inpatient psychiatric services: the percentage of patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan created.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan provided to the next level of care clinician or entity.

Hospital-based inpatient psychiatric services: the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

Hospital-based inpatient psychiatric services: the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.

Intensive care - ventilator-associated pneumonia (VAP) prevention: number of ventilator days where the patient's head of bed (HOB) is elevated equal to or greater than 30 degrees.

Intensive care: mean length of stay (LOS) for intensive care unit (ICU) by type of unit.

Intensive care: number of ventilator days where the patients received deep vein thrombolysis (DVT) prophylaxis.

Intensive care: number of ventilator days where the patients received stress ulcer disease (SUD) prophylaxis.

Intensive care: percent of central line-associated primary bloodstream infections (BSIs) by unit of attribution.

Intensive care: percentage of adult patients having had an intensive care unit (ICU) stay whose hospital outcome is death.

Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. [NQMC Update Pending]

Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]

Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. [NQMC Update Pending]

Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. [NQMC Update Pending]

Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. [NQMC Update Pending]

Pneumonia: percent of patients whose initial emergency department blood culture was performed prior to the administration of the first hospital dose of antibiotics. [NQMC Update Pending]

Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]

Pregnancy and related conditions: percent of live-born neonates who expire before the neonate becomes age 28 days.

Pregnancy and related conditions: percent of patients who have vaginal deliveries with third or fourth degree perineal laceration.

Pregnancy and related conditions: percent of patients with vaginal birth after cesarean section (VBAC).

Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. [NQMC Update Pending]

Surgical care improvement project: percent of colorectal surgery patients with immediate postoperative normothermia. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. [NQMC Update Pending]

Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. [NQMC Update Pending]

Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with appropriate hair removal. [NQMC Update Pending]

Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. [NQMC Update Pending]

Kolcaba, Katharine Ph.D.(1)

Comfort: score on General Comfort Questionnaire.

Manitoba Centre for Health Policy(13)

Anticoagulant medication management: percentage of patients with a 30-day supply (or more) of anticoagulants who had at least one blood clotting test per each 45-day period.

Antidepressant prescription follow-up: percentage of patients with a new prescription for an antidepressant associated with a depression diagnosis (within two weeks of each other) who had three subsequent ambulatory visits within four months of the prescription being filled.

Asthma care: percentage of patients with an asthma diagnosis (defined as one repeat prescription of a beta 2-agonist in the past year) who filled a prescription for medications recommended for long-term control of asthma (i.e., inhaled corticosteroids or leukotriene modifiers, and alternate anti-inflammatory medication).

Benzodiazepines: percentage of patients aged 75 years or older with prescription(s) for two or more benzodiazepines or prescriptions for greater than a 30-day supply of medication.

Blood sugar screening: percentage of patients aged 48 years or older who had at least one blood sugar test in the previous three years.

Cervical cancer screening: percentage of female patients aged 18 to 60 years who had not undergone a hysterectomy, and who had at least one Papaniculaou (Pap) test in the last three years.

Childhood immunization: percentage of patients who received their primary course of immunizations (i.e., DPT-HiB, polio x4, and MMR) by age 24 months.

Cholesterol screening: percentage of male patients aged 40 years or older and female patients aged 50 years or older who had at least one cholesterol screening test in the last five years.

Diabetes care: percentage of diabetic patients (defined as those who had at least one drug used to treat diabetes) who had a cholesterol screening test in the same fiscal year as the prescription.

Diabetes care: percentage of diabetic patients (defined as those who had at least one drug used to treat diabetes) who saw either an optometrist or ophthalmologist in the same fiscal year as the prescription.

Influenza vaccination: percentage of patients aged 65 years or older who received at least one influenza vaccine in the past two years.

Post-myocardial infarction care: percentage of patients discharged alive from hospital in the preceding three years with a discharge diagnosis of myocardial infarction (MI) (excluding those with prior diagnosis of asthma, chronic obstructive pulmonary disease [COPD] or peripheral vascular disease) who filled at least one prescription for a beta-blocker within four months of the first infarction.

Post-myocardial infarction care: percentage of patients discharged alive from hospital in the preceding three years with a discharge diagnosis of myocardial infarction (MI) who had a cholesterol test within four months of discharge.

McLean Hospital, Department of Mental Health Services Evaluation(7)

Mental health/substance abuse: mean of patient's change scores on the "Interpersonal Relationships" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Depression/Functioning" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Emotional Lability" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Psychosis" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Self-harm" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Substance Abuse" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' overall change scores on the BASIS-24® survey.

Mercer, Stewart W., BSc, MSc, PhD, MBChB, MRCGP(1)

Patients' experience with their general practice consultation: overall mean Consultation and Relational Empathy (CARE) score among patients who completed the CARE measure.

Mikuls, Ted M.D., M.S.P.H.(4)

Gout: percentage of patients with gout receiving an initial prescription for allopurinol and have significant renal impairment whose initial daily allopurinol dose is less than 300 mg per day.

Gout: percentage of patients with gout started on urate-lowering therapy who have either a history of nephrolithiasis or significant renal insufficiency who are started on a xanthine oxidase inhibitor as the initial urate-lowering medication rather than a uricosuric agent.

Gout: percentage of patients with hyperuricemia and gouty arthritis who are offered treatment with a urate-lowering drug.

Gout: percentage of patients with tophaceous gout who are given an initial prescription for a urate-lowering medication and lack both significant renal impairment and peptic ulcer disease who had a prophylactic anti-inflammatory agent given concomitantly.

National Committee for Quality Assurance(165)

Acute myocardial infarction (AMI): percentage of adult members 18 years of age and older with a diagnosis of AMI who received persistent beta-blocker treatment for six months after being discharged alive from the hospital. [NQMC Update Pending]

Adolescent well-care visits: percentage of members who were 12 through 21 years of age who had at least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner during the measurement year. [NQMC Update Pending]

Adults' access to preventive/ambulatory health services: percentage of members who had an ambulatory or preventive-care visit. [NQMC Update Pending]

Annual monitoring for patients on persistent medications: percentage of members 18 years of age and older who received at least a 180-days supply of ambulatory medication therapy for ACEIs or ARBs during the measurement year and at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. [NQMC Update Pending]

Annual monitoring for patients on persistent medications: percentage of members 18 years of age and older who received at least a 180-days supply of ambulatory medication therapy for anticonvulsants during the measurement year and at least one drug serum concentration level monitoring test for the prescribed drug in the measurement year. [NQMC Update Pending]

Annual monitoring for patients on persistent medications: percentage of members 18 years of age and older who received at least a 180-days supply of ambulatory medication therapy for digoxin during the measurement year and at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. [NQMC Update Pending]

Annual monitoring for patients on persistent medications: percentage of members 18 years of age and older who received at least a 180-days supply of ambulatory medication therapy for diuretics during the measurement year and at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. [NQMC Update Pending]

Antidepressant medication management (effective acute treatment phase): percentage of members who were diagnosed with a new episode of major depression and treated with antidepressant medication, who remained on an antidepressant drug during the entire 84-day (12-week) acute treatment phase. [NQMC Update Pending]

Antidepressant medication management (effective continuation phase treatment): percentage of members who were diagnosed with a new episode of major depression and treated with antidepressant medication, who remained on an antidepressant drug for at least 180 days. [NQMC Update Pending]

Appropriate testing for children with pharyngitis: percentage of children 2 to 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. [NQMC Update Pending]

Appropriate treatment for children with upper respiratory infection (URI): percentage of children 3 months to 18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription. [NQMC Update Pending]

Asthma: percentage of members 5 to 56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. [NQMC Update Pending]

Attention-deficit/hyperactivity disorder (ADHD) (continuation maintenance phase): percentage of members 6 to 12 years of age with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended. [NQMC Update Pending]

Attention-deficit/hyperactivity disorder (ADHD) (initiation phase): percentage of members 6 to 12 years of age with an ambulatory prescription dispensed for ADHD medication who had one follow-up visit with a practitioner with prescribing authority during the 30-day initiation phase. [NQMC Update Pending]

Avoidance of antibiotic treatment in adults with acute bronchitis: percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. [NQMC Update Pending]

Breast cancer screening: percentage of women 40 to 69 years of age who had one or more mammograms during the measurement year or the year prior to the measurement year. [NQMC Update Pending]

Cervical cancer screening: percentage of women 21 to 64 years of age who received one or more Pap tests during the measurement year or the two years prior to the measurement year. [NQMC Update Pending]

Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectible polio virus (IPV), one measles-mumps-rubella (MMR), three haemophilus influenza type B (HiB), three hepatitis B, one chicken pox vaccination (VZV) and four pneumococcal conjugate vaccinations by their second birthday (combination #3). [NQMC Update Pending]

Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP/DT), three injectible polio virus (IPV), one measles-mumps-rubella (MMR), three haemophilus influenza type B (HiB), three hepatitis B and one chicken pox vaccination (VZV) by their second birthday (combination #2). [NQMC Update Pending]

Children and adolescents' access to primary care practitioners: percentage of members who had a visit with a primary care practitioner. [NQMC Update Pending]

Chlamydia screening: percentage of women 16 to 25 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. [NQMC Update Pending]

Cholesterol management for patients with cardiovascular conditions: percentage of patients with a cardiovascular condition who had a low-density lipoprotein cholesterol (LDL-C) screening performed and the percentage of patients who have a documented LDL-C level less than 100 mg/dL. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): percentage of health plan members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. [NQMC Update Pending]

Colorectal cancer screening: percentage of adults 50 to 80 years of age who had appropriate screening for colorectal cancer. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) who had a hemoglobin A1c (HbA1c) test during the measurement year. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) who had a nephropathy screening test or evidence of nephropathy. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) who had an eye screening for diabetic retinal disease. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) who had low-density lipoprotein cholesterol (LDL-C) test performed. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) whose most recent blood pressure reading is less than 130/80 mm Hg. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) whose most recent blood pressure reading is less than 140/90 mm Hg. [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) whose most recent hemoglobin A1c (HbA1c) level is greater than 9.0% (poorly controlled). [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) whose most recent hemoglobin A1c (HbA1c) level is less than 7.0% (good control). [NQMC Update Pending]

Comprehensive diabetes care: percentage of members 18 through 75 years of age with diabetes mellitus (type 1 and type 2) whose most recent low-density lipoprotein cholesterol (LDL-C) level is less than 100 mg/dL. [NQMC Update Pending]

Dental care: percentage of members 2 through 21 years of age who had at least one dental visit during the measurement year. [NQMC Update Pending]

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.

Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.

Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.

Emergency medicine: percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.

Engagement of alcohol and other drug (AOD) treatment: percentage of adolescent and adult members who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. [NQMC Update Pending]

Eye care: percentage of patients aged 18 years and older with a diagnosis of cataracts who were assessed for visual functional status during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.

Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.

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

Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.

Fall risk management: the percentage of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by an MAO practitioner in the past 12 months and who received fall risk intervention from their current practitioner. [NQMC Update Pending]

Fall risk management: the percentage of Medicare members 75 years of age and older or who are 65 to 74 years of age with balance or walking problems or a fall in the past 12 months who were seen by an MAO practitioner in the past 12 months and who discussed fall or problems with balance or walking with their current practitioner. [NQMC Update Pending]

Frequency of ongoing prenatal care: percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received less than 21%, 21% to 40%, 41% to 60%, 61% to 80%, or greater than or equal to 81% of the expected number of prenatal care visits. [NQMC Update Pending]

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.

Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

Geriatrics: 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.

Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.

Glaucoma screening: percentage of Medicare members 65 years and older without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye-care professional for the early identification of glaucomatous conditions. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy to get needed care. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often their doctor and other health provider talked about specific things they could do to prevent illness.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors communicated well. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often their health plans handled their claims quickly and correctly. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor seemed informed and up-to-date about care they got from other doctors or other health providers. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often they were able to find out from their health plan how much they would have to pay for a healthcare service or specific prescription medicines. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan's customer service. [NQMC Update Pending]

Health plan members' experiences: percentage of adult health plan members who reported whether a doctor or other health provider included them in shared decision making. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had in getting needed care for their child. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with health plan customer service for their child. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child got care quickly. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child's doctors or other health providers communicated well. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences in getting needed information for their children with chronic conditions. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences with their children's personal doctor or nurse for their children with chronic conditions. [NQMC Update Pending]

Health plan members' experiences: percentage of parents or guardians of health plan members who reported they received assistance with coordination of care and services for their children with chronic conditions. [NQMC Update Pending]

Health plan members' satisfaction with care: adult health plan members' ratings of all health care received from their health plan in the last 12 months. [NQMC Update Pending]

Health plan members' satisfaction with care: adult health plan members' ratings of the specialist they saw most often. [NQMC Update Pending]

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan. [NQMC Update Pending]

Health plan members' satisfaction with care: adult health plan members' ratings of their personal doctor. [NQMC Update Pending]

Health plan members' satisfaction with care: parents' or guardians' ratings of the specialist their child saw most often. [NQMC Update Pending]

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health care. [NQMC Update Pending]

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health plan. [NQMC Update Pending]

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's personal doctor. [NQMC Update Pending]

Hypertension: percentage of members 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (BP less than or equal to 140/90 mm Hg) during the measurement year. [NQMC Update Pending]

Influenza immunization: percentage of Medicare members 65 years of age and older who received an influenza vaccination between September 1 of the measurement year and the date on which the Medicare CAHPS survey was completed. [NQMC Update Pending]

Influenza immunization: percentage of members 50 to 64 years of age who received an influenza vaccination between September 1 of the measurement year and the date on which the CAHPS® 4.0H Adult Survey was completed. [NQMC Update Pending]

Initiation of alcohol and other drug (AOD) treatment: percentage of adolescent and adult members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of diagnosis. [NQMC Update Pending]

Lead screening in children: percentage of children two years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday. [NQMC Update Pending]

Management of urinary incontinence in older adults: percentage of Medicare members 65 years of age and older who reported having a urine leakage problem in the past six months and who discussed their urinary leakage problem with their current practitioner. [NQMC Update Pending]

Management of urinary incontinence in older adults: percentage of Medicare members 65 years of age and older who reported having a urine leakage problem in the past six months and who received treatment for their current urine leakage problem. [NQMC Update Pending]

Melanoma: percentage of patients with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.

Melanoma: percentage of patients with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.

Melanoma: percentage of patients with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Melanoma: percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.

Mental health: percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 30 days of discharge. [NQMC Update Pending]

Mental health: percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge. [NQMC Update Pending]

Osteoporosis management in women who had a fracture: percentage of women 67 years of age and older who suffered a fracture, and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. [NQMC Update Pending]

Osteoporosis testing in older women: the percentage of female Medicare members 65 years of age and over who report ever having received a bone density test to check for osteoporosis. [NQMC Update Pending]

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

Perioperative care: 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.

Perioperative care: percentage of non-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 24 hours of surgical end time.

Perioperative care: percentage of patients 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 24 hours after surgery end time.

Perioperative care: 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 cefazolin or cefuroxime for antimicrobial prophylaxis.

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

Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

Pharmacotherapy management of COPD exacerbation: percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to December 1 of the measurement year and who were dispensed a bronchodilator within 30 days of the event. [NQMC Update Pending]

Pharmacotherapy management of COPD exacerbation: percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to December 1 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event. [NQMC Update Pending]

Physical activity in older adults: percentage of Medicare members 65 years of age and older who had a doctor's visit in the past 12 months and who received advice to start, increase or maintain their level of exercise or physical activity. [NQMC Update Pending]

Physical activity in older adults: percentage of Medicare members 65 years of age and older who had a doctor's visit in the past 12 months and who spoke with a doctor or other health provider about their level of exercise or physical activity. [NQMC Update Pending]

Pneumonia vaccination status: percentage of Medicare members 65 years of age and older who have ever received a pneumococcal vaccination. [NQMC Update Pending]

Postpartum care: percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. [NQMC Update Pending]

Potentially harmful drug-disease interactions in the elderly: percentage of Medicare members 65 years of age and older who have a diagnosis of chronic renal failure and prescription for non-aspirin NSAIDs or Cox-2 Selective NSAIDs. [NQMC Update Pending]

Potentially harmful drug-disease interactions in the elderly: percentage of Medicare members 65 years of age and older who have a diagnosis of dementia and a prescription for tricyclic antidepressants or anticholinergic agents. [NQMC Update Pending]

Potentially harmful drug-disease interactions in the elderly: percentage of Medicare members 65 years of age and older who have a history of falls and a prescription for tricyclic antidepressants, antipsychotics or sleep agents. [NQMC Update Pending]

Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.

Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.

Radiology: percentage of final reports for screening mammograms that are classified "probably benign".

Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.

Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.

Rheumatoid arthritis: percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). [NQMC Update Pending]

Smoking cessation: percentage of members 18 years and older who were current smokers, who were seen by a health plan practitioner during the measurement year for whom discussed or were recommended smoking cessation methods or strategies. [NQMC Update Pending]

Smoking cessation: percentage of members 18 years of age and older who are current smokers, who were seen by a health plan practitioner during the measurement year and who received advice to quit smoking. [NQMC Update Pending]

Smoking cessation: percentage of members 18 years of age and older who are current smokers, who were seen by a health plan practitioner during the measurement year for whom discussed or were recommended smoking cessation medications. [NQMC Update Pending]

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.

The Medicare Health Outcomes Survey: percentage of members whose health status was "better," "the same" or "worse than expected" at the end of a two-year period. [NQMC Update Pending]

Timeliness of prenatal care: percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. [NQMC Update Pending]

Use of high-risk medications in the elderly: percentage of Medicare members 65 years of age and older who received at least one high-risk medication. [NQMC Update Pending]

Use of high-risk medications in the elderly: percentage of Medicare members 65 years of age and older who received at least two different high-risk medications [NQMC Update Pending]

Use of imaging studies for low back pain: percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis. [NQMC Update Pending]

Well-child visits in the first 15 months of life: percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a primary care practitioner (PCP) during their first 15 months of life: zero, one, two, three, four, five, six or more. [NQMC Update Pending]

Well-child visits in the third, fourth, fifth and sixth years of life: percentage of members who were three to six years of age during the measurement year who received one or more well-child visits with a primary care practitioner (PCP) during the measurement year. [NQMC Update Pending]

National Diabetes Quality Improvement Alliance(20)

Adult diabetes: percentage of eligible patients receiving at least one foot exam, defined in any manner.

Adult diabetes: percentage of eligible patients who received an immunization or refused immunization during the calendar period.

Adult diabetes: percentage of patients assessed for smoking status.

Adult diabetes: percentage of patients receiving a dilated retinal eye exam by an ophthalmologist or optometrist.

Adult diabetes: percentage of patients receiving a funduscopic photo with interpretation by an ophthalmologist or optometrist.

Adult diabetes: percentage of patients receiving at least one complete foot examination (visual inspection, sensory exam with monofilament, and pulse exam).

Adult diabetes: percentage of patients receiving at least one lipid profile (or ALL component tests).

Adult diabetes: percentage of patients receiving one or more A1c test(s).

Adult diabetes: percentage of patients who received a dilated eye examination or evaluation of retinal photographs if patient is at low risk for retinopathy.

Adult diabetes: percentage of patients who received an influenza immunization during the recommended calendar period.

Adult diabetes: percentage of patients who received any test for microalbuminuria.

Adult diabetes: percentage of patients who were prescribed aspirin therapy (dose greater than or equal to 75 mg).

Adult diabetes: percentage of patients whose smoking status was ascertained and documented annually.

Adult diabetes: percentage of patients with at least one LDL-C test.

Adult diabetes: percentage of patients with at least one test for microalbumin during the measurement year; or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria).

Adult diabetes: percentage of patients with most recent A1c level greater than 9.0% (poor control).

Adult diabetes: percentage of patients with most recent blood pressure less than 140/90 mm Hg.

Adult diabetes: percentage of patients with most recent LDL-C less than 130 mg/dL.

Adult diabetes: percentage of patients with no urinalysis or urinalysis with negative or trace urine protein, who received a test for microalbumin.

Adult diabetes: percentage of smokers who were recommended or offered an intervention for smoking cessation (i.e., counseling or pharmacologic therapy).

National Health System (NHS) Confederation(80)

Asthma: the percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability and reversibility. [NQMC Update Pending]

Asthma: the percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months. [NQMC Update Pending]

Asthma: the percentage of patients with asthma who have had an asthma review in the previous 15 months. [NQMC Update Pending]

Asthma: the practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the previous twelve months. [NQMC Update Pending]

Atrial fibrillation: the percentage of patients with atrial fibrillation diagnosed after 1 April 2006 with electrocardiogram (ECG) or specialist confirmed diagnosis. [NQMC Update Pending]

Atrial fibrillation: the percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy. [NQMC Update Pending]

Atrial fibrillation: the practice can produce a register of patients with atrial fibrillation. [NQMC Update Pending]

Cancer: the percentage of patients with cancer diagnosed from 1 April 2003 with a review by the practice recorded within six months of confirmed diagnosis. [NQMC Update Pending]

Cancer: the practice can produce a register of all cancer patients defined as a 'register of patients with a diagnosis of cancer excluding nonmelanotic skin cancers from 1 April 2003.' [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less. [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]

Chronic kidney disease (CKD): the percentage of patients on the CKD register with hypertension who are treated with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded). [NQMC Update Pending]

Chronic kidney disease (CKD): the practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD). [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 15 months. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD with a record of FeV1 in the previous 15 months. [NQMC Update Pending]

Chronic obstructive pulmonary disease (COPD): the practice can produce a register of patients with COPD. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an angiotensin-converting enzyme (ACE) inhibitor or Angiotensin II antagonist. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the last 15 months) is 150/90 mm Hg or less. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]

Coronary heart disease: the percentage of patients with coronary heart disease with a record in the previous 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Coronary heart disease: the percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment. [NQMC Update Pending]

Coronary heart disease: the practice can produce a register of patients with coronary heart disease. [NQMC Update Pending]

Dementia: the percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months. [NQMC Update Pending]

Dementia: the practice can produce a register of patients diagnosed with dementia. [NQMC Update Pending]

Depression: the percentage of patients with a new diagnosis of depression, recorded between the preceeding 1 April to 31 March, who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care. [NQMC Update Pending]

Depression: the percentage of patients with diabetes and/or coronary heart disease (CHD) for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last blood pressure is 145/85 or less. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 10 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of HbA1c or equivalent in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria). [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of retinal screening in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes whose notes record body mass index (BMI) in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II [A2] antagonists). [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months. [NQMC Update Pending]

Diabetes mellitus: the practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of medication review involving the patient and/or carer in the previous 15 months. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months. [NQMC Update Pending]

Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the previous 15 months. [NQMC Update Pending]

Epilepsy: the practice can produce a register of patients age 18 years and over receiving drug treatment for epilepsy. [NQMC Update Pending]

Heart failure: the percentage of patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), who can tolerate therapy and for whom there is no contraindication. [NQMC Update Pending]

Heart failure: the percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment. [NQMC Update Pending]

Heart failure: the practice can produce a register of patients with heart failure. [NQMC Update Pending]

Hypertension: the percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less. [NQMC Update Pending]

Hypertension: the percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months. [NQMC Update Pending]

Hypertension: the practice can produce a register of patients with established hypertension. [NQMC Update Pending]

Hypothyroidism: the percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months. [NQMC Update Pending]

Hypothyroidism: the practice can produce a register of patients with hypothyroidism. [NQMC Update Pending]

Learning disabilities: the practice can produce a register or patients with learning disabilities. [NQMC Update Pending]

Mental health: the percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months. [NQMC Update Pending]

Mental health: the percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months. [NQMC Update Pending]

Mental health: the percentage of patients on the mental health register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate. [NQMC Update Pending]

Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance. [NQMC Update Pending]

Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. [NQMC Update Pending]

Mental health: the practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses. [NQMC Update Pending]

Obesity: the practice can produce a register of patients aged 16 and over with a body mass index (BMI) greater than or equal to 30 in the previous 15 months. [NQMC Update Pending]

Palliative care: the practice has a complete register available of all patients in need of palliative care/support. [NQMC Update Pending]

Palliative care: the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. [NQMC Update Pending]

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. [NQMC Update Pending]

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma whose notes record smoking status in the previous 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of new patients with a stroke who have been referred for further investigation. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in previous 15 months) is 150/90 or less. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke whose last measured total cholesterol (measured in previous 15 months) is 5 mmol/l or less. [NQMC Update Pending]

Stroke and transient ischaemic attack (TIA): the practice can produce a register of patients with stroke or TIA. [NQMC Update Pending]

New York State Department of Health AIDS Institute(175)

HIV ambulatory care satisfaction: HIV positive adolescent and adult patients ratings of the care provided to them at their clinic.

HIV ambulatory care satisfaction: HIV positive adolescent and adult patients' ratings of the quality of care at their clinic in comparison to other clinics they know about.

HIV ambulatory care satisfaction: HIV positive adolescent and adult patients' ratings of their providers' knowledge of the newest developments in HIV medical standards.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often HIV-specific educational materials were available for them to read.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often it was hard for them to get their HIV medication prescriptions filled when they needed them.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often the staff and their providers kept their HIV status confidential.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often the staff were unfriendly to them while they checked in and waited for their visit.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager and their HIV medical care providers worked together to help them.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager helped them get services at their clinic and, if needed, at other places.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager involved their family and friends in their care as much as they needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager was able to work quickly to get them what they needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager was good at showing them how they could help themselves.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager was responsible and professional.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their case manager went over their service plan and updated it with them every 3 months.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their life ran more smoothly overall because of the help they got from their case manager.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their providers ignored a complaint about their medical care.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their providers made sure they understood what their lab test results (such as CD4 and viral load) meant for their health.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their providers told them how important it was to keep their appointments.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their providers' answers to their questions about their HIV health care were hard to understand.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often their visits with their providers got interrupted (by phone calls, other patients, etc.).

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they could get someone on the phone to discuss a medical question.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they could reach someone at the clinic during off hours (evenings and weekends) who could help them.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they could schedule an appointment soon enough for my needs when needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they could see their case manager soon enough for their needs when they needed an appointment.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they did not get the medical care they needed because they could not pay for it.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they felt comfortable sharing their feelings and problems with their case manager.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they felt they would get in trouble if they disagreed with or complained about their case manager.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they felt uncomfortable talking about personal or intimate issues with their providers.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they found it hard to talk to their case manager.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they found their providers to be accepting and non-judgmental of their life and health care choices.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they got services in the language they wanted.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they had questions they wanted to ask their providers about their HIV care but did not ask.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they thought about leaving their clinic to find better care somewhere else.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they wanted their case manager to spend more time with them to help them with their problems.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they wanted their providers to spend more time with them.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they wanted to be more involved in making decisions about their health care.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they wanted to be more involved in making decisions about their service plan and goals.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they were able to get the services their provider referred them to.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported how often they were upset by how long they had to wait for their appointment.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported the reasons they felt may have caused them to be treated poorly at their clinic (if applicable).

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported what it was like when they called the clinic to schedule an appointment.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether if they knew someone who was HIV-positive and needed a case manager, they would refer her or him to this program for help.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers asked them about how they were eating and made a referral to a nutritionist if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers asked them about their drug and alcohol use and made a referral if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers asked them about their teeth and made a referral to a dentist if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers asked them whether they needed help to tell their sexual partners about their HIV status and made a referral if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers explained the side effects of their HIV medications in a way they could understand.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers explained to them how to avoid getting sick.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers explained to them what kinds of medical tests they should be getting and how often they should get them.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers or case managers asked them about their life situation (housing, their finances, etc.), and made a referral if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers or case managers asked them how they were feeling emotionally and made a referral to a mental health provider, counselor, or support group if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers suggested ways to help them remember to take their HIV medications.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers talked to them about how to avoid passing HIV to other people and how to protect themselves from getting infected again with HIV.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether their providers talked to them about how to protect themselves from getting hepatitis C (Hep C) or how to avoid passing it on to others if they already had it.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether they were satisfied overall with the case management services they received over the past 12 months.

HIV ambulatory care satisfaction: percentage of HIV positive adolescent and adult patients who reported whether they would recommend their clinic to their HIV-positive friends with similar needs.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients in a methadone maintenance program who reported how often the dispensing line was too slow.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often it was difficult to get referrals to specialists in their plan.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often the program rules were enforced fairly by the staff.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often the written materials about their plan and its benefits were difficult to understand.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their mental health providers and their HIV medical providers worked together to help them.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their mental health providers didn't seem to care how they were feeling.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their mental health providers involved their family and friends in their mental health treatment as much as they wanted.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their mental health providers knew how HIV affects their mental health.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their mental health providers were responsible and professional.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their plan covered alcohol and drug use treatment as much as they needed.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their plan covered mental health services as much as they needed.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their plan protected their confidentiality.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their plan took it seriously when they had a complaint.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their plan was good at making sure that their children's health care and their HIV-positive partner's health care were covered.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their substance use counselors knew about both substance use and HIV.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their substance use counselors were responsible and professional.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often their substance use counselors, case manager, and HIV medical providers worked together to help them.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they considered changing from their plan to another one.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they could see their mental health providers soon enough for their needs when they needed an appointment.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they could see their substance use counselors soon enough for their needs when they needed an appointment.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they felt comfortable sharing their feelings and problems with their mental health providers.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they felt they would get in trouble if they disagreed with or complained about their mental health providers.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they felt they would get in trouble if they disagreed with or complained about their substance use counselors.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they found it hard to relate to their substance use counselors.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they found it hard to talk to their mental health providers.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they had difficulty getting the HIV care they needed.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they had to go to an emergency room to get care.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they wanted a service that was not covered by their plan.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they wanted their mental health providers to spend more time with them to help them deal with their problems.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they wanted to be more involved in making decisions about their mental health treatment.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they wanted to see a doctor that was outside of their plan.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they were afraid of being seen going to HIV services in the facility.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported how often they wished that the classes they went to had taught them more about taking care of themselves.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported their whether they were satisfied overall with the substance use services they received over the past 12 months.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether clients should have more help in transitioning out of the program.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether if they knew someone who was HIV-positive and had a substance use problem, they would refer her or him to this program for help.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether if they knew someone who was HIV-positive and had mental health problems, they would refer her or him to this program for help.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether if they knew someone who was HIV-positive and on Medicaid, they would recommend this plan to him or her.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether overall, they were satisfied with this Medicaid managed care plan during the past 12 months.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether someone explained their Medicaid managed care plan to them in a way they could understand.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether the program helped them to feel better about themselves.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether the program helped them to reduce their substance use.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their HIV care improved after switching to a managed care plan.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their providers explained to them in a way they could understand how their psychiatric medications interact with their HIV medications.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their substance use counselors explained to them in a way they could understand how their substance use treatment (for example, methadone) and their HIV medications might interact.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their substance use counselors helped them get into a residential drug treatment program if needed.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their substance use counselors helped them to achieve their substance use treatment plan goals.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether their substance use counselors understood where they were with their recovery and helped them to reduce or eliminate their drug use.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they felt better overall as a result of their mental health treatment.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they needed more information about the purpose of their psychiatric medications and their side effects.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they wanted to have more time in group therapy to meet their needs.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they wanted to have more time in group therapy to meet their needs.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they wanted to have more time in individual therapy to meet their needs.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they were discouraged from joining their managed care plan because they were HIV-positive.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether they were satisfied overall with the mental health services they received over the past 12 months.

HIV ambulatory care satisfaction: percentage of HIV positive adult patients who reported whether, if they relapsed, their substance use counselors explained ways to reduce the harm of drug use.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often it was difficult to get an appointment with their women's health providers for a date and time they wanted.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often the clinic provided adequate child care during their appointments.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often their women's health care providers and their HIV medical providers worked together to help them.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often their women's health providers explained to them what was going to be done during the physical exam.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often their women's health providers knew about the latest medical developments for women with HIV.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often their women's health providers were responsible and professional.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often they felt comfortable talking to their women's health providers about their sex life.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often they felt they would get in trouble if they disagreed with or complained about their women's health providers.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often they found it hard to talk to their women's health providers.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported how often they wanted to be more involved in making decisions about their care.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether if they knew a woman who was HIV-positive and needed medical care, they would refer her to this program.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether their women's health providers helped them understand the differences between symptoms of normal aging, HIV symptoms, and side affects of medication.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether their women's health providers screened them for sexually transmitted diseases.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether they had questions about menopause, but their women's health providers did not answer them in a way they could understand.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether they had questions about pregnancy and prenatal care, but their women's health providers did not answer them in a way that they could understand.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether they had questions about using or getting birth control, but their women's health providers did not answer them in a way they could understand.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether they were satisfied overall with the women's health care they received over the past 12 months.

HIV ambulatory care satisfaction: percentage of HIV positive women who reported whether, overall, their women's health care has helped them.

HIV: percentage of adult and adolescent hepatitis C virus (HCV)-positive patients for whom alcohol counseling and HCV education was provided.

HIV: percentage of adult and adolescent patients for whom a CD4 count test was performed every four months.

HIV: percentage of adult and adolescent patients for whom a follow-up clinic visit is recorded every four months.

HIV: percentage of adult and adolescent patients for whom a mental health assessment was performed during the past year.

HIV: percentage of adult and adolescent patients for whom a viral load test was performed every four months.

HIV: percentage of adult and adolescent patients for whom hepatitis A status was documented.

HIV: percentage of adult and adolescent patients for whom hepatitis C status was documented in the medical record.

HIV: percentage of adult and adolescent patients for whom one of four specified management options is documented in the medical record in every 4-month period the patient is considered unstable.

HIV: percentage of adult and adolescent patients for whom purified protein derivative (PPD) was placed and results read during the past year.

HIV: percentage of adult and adolescent patients prescribed antiretroviral therapy for whom adherence is measured and described quantitatively at least once every four months.

HIV: percentage of adult and adolescent patients who are stable on antiretroviral (ARV) therapy for whom viral load is monitored every four months.

HIV: percentage of adult and adolescent patients with a pelvic exam and Papanicolaou (Pap) smear recorded in the past year.

HIV: percentage of adult and adolescent patients with current use (0 to 6 months from date of review) and not in treatment for whom referrals are made for substance use treatment.

HIV: percentage of adult and adolescent patients with past use (6 to 24 months from date of review) with whom relapse prevention or ongoing treatment has been discussed, and substance use within the last 12 months assessed.

HIV: percentage of adult and adolescent patients with whom substance use was discussed during the past year.

HIV: percentage of adult and adolescent patients with whom tobacco use was discussed during the past year.

HIV: percentage of nursing facility patients for whom a follow-up clinic visit is recorded every four months.

HIV: percentage of nursing facility patients for whom a viral load test was performed every four months.

HIV: percentage of nursing facility patients for whom active tuberculosis (TB) was excluded prior to admission.

HIV: percentage of nursing facility patients for whom CD4 was measured within the four-month review period.

HIV: percentage of nursing facility patients for whom hepatitis A immune status was documented.

HIV: percentage of nursing facility patients for whom hepatitis B immune status was documented.

HIV: percentage of nursing facility patients for whom hepatitis C immune status was documented.

HIV: percentage of nursing facility patients for whom lipid screening was performed during the past year.

HIV: percentage of nursing facility patients for whom mammography was recorded in the past year.

HIV: percentage of nursing facility patients for whom one of four specified management options is documented in the medical record in every 4-month period the patient is considered unstable.

HIV: percentage of nursing facility patients for whom purified protein derivative (PPD) was placed and results read during the past year.

HIV: percentage of nursing facility patients placed on Mycobacterium avium complex (MAC) prophylaxis (rifabutin, clarithromycin, azithromycin or other).

HIV: percentage of nursing facility patients placed on Pneumocystis carinii pneumonia (PCP) prophylaxis (trimethoprim-sulfamethoxazole [TMP/SMX], atovaquone, dapsone, pentamidine, or other).

HIV: percentage of nursing facility patients who are stable on antiretroviral (ARV) therapy for whom viral load is monitored every four months.

HIV: percentage of nursing facility patients with a baseline toxoplasma serology documented.

HIV: percentage of nursing facility patients with a pelvic exam and Papanicolaou (Pap) smear with follow-up abnormal results recorded in the past year.

HIV: percentage of pediatric patients for whom a viral load test is performed every 4 months.

HIV: percentage of pediatric patients for whom adherence is assessed and quantified at least once every 4 months.

HIV: percentage of pediatric patients for whom CD4 count is measured every 4 months.

HIV: percentage of pediatric patients for whom DTaP, IPV, HIB, Hep B, MMR, pneumococcal, (and varicella, if asymptomatic and immunologic class 1) are provided.

HIV: percentage of pediatric patients for whom influenza immunization is performed annually.

HIV: percentage of pediatric patients for whom one of four specified management options is documented in the medical record in every 4-month period the patient is considered unstable.

HIV: percentage of pediatric patients less than 2 years of age for whom neurodevelopmental assessments are monitored annually.

HIV: percentage of pediatric patients prescribed prophylactic therapy according to immunologic status.

HIV: percentage of pediatric patients who are seen by an HIV Specialist at least once every 4 months.

HIV: percentage of pediatric patients who are stable on antiretroviral (ARV) therapy for whom viral load or CD4 count is monitored every 4 months.

HIV: percentage of pediatric patients whose multidisciplinary care plan incorporates case management and nursing services.

HIV: percentage of pediatric patients with no other therapeutic options available for whom viral load is monitored every 4 months.

HIV: percentage of pregnant women with counseling offered and testing performed during the prenatal period.

Physician Consortium for Performance Improvement®(191)

Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.

Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.

Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees).

Anesthesiology and critical care: percentage of patients who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique followed.

Anesthesiology and critical care: percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

Asthma: percentage of patients aged 5 to 40 years diagnosed with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.

Asthma: percentage of patients aged 5 to 40 years with diagnosed asthma who were evaluated during at least one office visit during the reporting year for the frequency (numeric) of daytime and nocturnal asthma symptoms.

Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.

Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.

Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February).

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period.

Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for COPD symptoms at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older who had a spirometry evaluation results documented at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and an oxygen saturation less than or equal to 88% or a PaO2 less than or equal to 55 mm Hg who prescribed long term oxygen therapy.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and dyspnea for whom exercise training was recommended.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and FEV1 less than 40% of predicted value who have oxygen saturation assessed at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD identified as smokers who received a smoking cessation intervention at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received a pneumococcus immunization.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received influenza immunization during current flu season.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for pneumococcus immunization status.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were queried about smoking at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were recommended to receive an influenza immunization annually.

Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.

Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.

Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.

Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.

Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.

Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.

Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.

Community-acquired bacterial pneumonia: percentage of patients who had a documented rationale for level of care based on severity and safety of home care.

Community-acquired bacterial pneumonia: percentage of patients who received a smoking cessation intervention.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for co-morbid conditions.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for influenza immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for pneumococcus immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were prescribed an appropriate empiric antibiotic.

Community-acquired bacterial pneumonia: percentage of patients who were queried about smoking.

Community-acquired bacterial pneumonia: percentage of patients with a chest x-ray performed.

Community-acquired bacterial pneumonia: percentage of patients with hydration status assessed.

Community-acquired bacterial pneumonia: percentage of patients with mental status assessed.

Community-acquired bacterial pneumonia: percentage of patients with oxygen saturation assessed.

Community-acquired bacterial pneumonia: percentage of patients with vital signs recorded.

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.

Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.

Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.

Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.

Emergency medicine: percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V greater than or equal to 1.2 OR patients have a Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD who are receiving dialysis have a Hgb greater than or equal to 11g/dL OR have a Hgb less than 11g/dL with a documented plan of care for anemia.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the flu season (September through February).

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula OR patients who are referred for an AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis with a permanent catheter who are referred for evaluation for AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times during the 12 month reporting period.

Eye care: percentage of patients aged 18 years and older with a diagnosis of cataracts who were assessed for visual functional status during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.

Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.

Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.

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

Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.

Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.

Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

Geriatrics: 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.

Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.

Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.

Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.

Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.

Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.

Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.

Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.

Hypertension: percentage of patient visits with blood pressure measurement recorded.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who receive therapy appropriate to their classification during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who were initially treated with antidepressant medication who had the antidepressant medication discontinued who were continued on antidepressant medication for a minimum of 16 weeks following remission of symptoms during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD whose severity of depressive disorder was assessed during the visit in which the new diagnosis or recurrent episode was identified during the measurement period.

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD, who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified.

Melanoma: percentage of patients with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.

Melanoma: percentage of patients with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.

Melanoma: percentage of patients with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Melanoma: percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.

Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.

Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.

Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.

Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.

Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.

Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.

Osteoarthritis: percentage of patient visits during which an anti-inflammatory agent or analgesic was considered.

Osteoarthritis: percentage of patient visits during which gastrointestinal (GI) prophylaxis was considered.

Osteoarthritis: percentage of patient visits during which therapeutic exercise for the knee (therapeutic exercise instructed or physical therapy prescribed) was considered.

Osteoarthritis: percentage of patient visits with assessment for function and pain.

Osteoarthritis: percentage of patient visits with assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications.

Osteoarthritis: percentage of patients for whom a physical examination of the involved joint was performed during the initial visit.

Osteoarthritis: percentage of patients on prescribed or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) who were assessed for gastrointestinal (GI)/renal risk factors.

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

Otitis media with effusion (OME): percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids.

Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed/recommended either antihistamines or decongestants.

Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Pathology: percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.

Perioperative care: 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.

Perioperative care: percentage of non-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 24 hours of surgical end time.

Perioperative care: percentage of patients 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 24 hours after surgery end time.

Perioperative care: 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 cefazolin or cefuroxime for antimicrobial prophylaxis.

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

Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

Prenatal care: percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation.

Prenatal care: percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit.

Preventive care and screening: percentage of female patients who had a mammogram performed during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients identified as tobacco users who received cessation intervention during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients screened for colorectal cancer during the one-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who received an influenza immunization during the one-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who were queried about and screened for problem drinking during the two-year measurement period. [NQMC Update Pending]

Preventive care and screening: percentage of patients who were queried about tobacco use one or more times during the two-year measurement period. [NQMC Update Pending]

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.

Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.

Prostate cancer: percentage of patients, regardless of age, with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.

Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.

Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.

Radiology: percentage of final reports for screening mammograms that are classified "probably benign".

Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.

Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.

Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.

Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.

Press Ganey Associates, Inc.(63)

Emergency department satisfaction: mean section score for "Arrival" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Doctors" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Family or Friends" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Nurses" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Overall Assessment" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Personal Issues" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Personal/Insurance Information" questions on Emergency Department Survey.

Emergency department satisfaction: mean section score for "Tests" questions on Emergency Department Survey.

Home health care satisfaction: mean section score for "Arranging Your Home Health Care" questions on Home Health Care Survey.

Home health care satisfaction: mean section score for "Managing Your Home Health Care" questions on Home Health Care Survey.

Home health care satisfaction: mean section score for "Nurses" questions on Home Health Care Survey.

Home health care satisfaction: mean section score for "Overall Ratings" questions on Home Health Care Survey.

Home health care satisfaction: mean section score for "Personal Issues" questions on Home Health Care Survey.

Hospice services satisfaction: mean section score for "Arranging Hospice Care" questions on Hospice Services Survey.

Hospice services satisfaction: mean section score for "Dealing with the Hospice Office" questions on Hospice Services Survey.

Hospice services satisfaction: mean section score for "Hospice Team" questions on Hospice Services Survey.

Hospice services satisfaction: mean section score for "Overall Assessment" questions on Hospice Services Survey.

Hospice services satisfaction: mean section score for "Personal Issues" questions on Hospice Services Survey.

Inpatient pediatric satisfaction: mean section score for "Admission" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Discharge" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Family and Visitors" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Meals" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Nursing Care" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Overall Assessment" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Personal Issues" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Tests and Treatments" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Your Child's Physician" questions on Inpatient Pediatric Survey.

Inpatient pediatric satisfaction: mean section score for "Your Child's Room" questions on Inpatient Pediatric Survey.

Inpatient satisfaction: mean section score for "Admission" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Discharge" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Meals" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Nurses" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Overall Assessment" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Personal Issues" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Physician" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Room" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Tests and Treatments" questions on Inpatient Survey.

Inpatient satisfaction: mean section score for "Visitors and Family" questions on Inpatient Survey.

Medical practice satisfaction: mean section score for "Access to Care" questions on Medical Practice Survey.

Medical practice satisfaction: mean section score for "During Your Visit" questions on Medical Practice Survey.

Medical practice satisfaction: mean section score for "Overall Assessment" questions on Medical Practice Survey.

Medical practice satisfaction: mean section score for "Personal Issues" questions on Medical Practice Survey.

Medical practice satisfaction: mean section score for "Your Care Provider" questions on Medical Practice Survey.

Nursing home family satisfaction: mean section score for "Activities" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Admission" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Certified Nursing Assistants" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Dining" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Final Ratings" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Finances" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Housekeeping Services" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Maintenance" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Nurses" questions on Nursing Home Family Survey.

Nursing home family satisfaction: mean section score for "Room" questions on Nursing Home Family Survey.

Nursing home resident satisfaction: mean section score for "Activities" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Admission" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Certified Nursing Assistants" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Dining" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Final Ratings" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Finances" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Housekeeping Services" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Maintenance" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Nurses" questions on Nursing Home Resident Survey.

Nursing home resident satisfaction: mean section score for "Room" questions on Nursing Home Resident Survey.

RAND Health(51)

Acetaminophen use: percentage of patients prescribed acetaminophen who have risk factors for liver disease AND the percentage of patients treated with high-dose (greater than or equal to 4 gm/day) acetaminophen who are advised of the associated risk of liver toxicity.

Cyclooxygenase 2 (COX-2)-selective non-steroidal anti-inflammatory drug (NSAID) use: percentage of patients treated with a COX-2-selective NSAID who are taking low-dose aspirin daily and have risk factors for GI bleeding who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Low-dose aspirin use: percentage of patients treated with a low-dose aspirin daily who have 2 or more risk factors for GI bleeding who are treated concomitantly with either misoprostol or proton pump inhibitor (PPI).

Low-dose aspirin: percentage of patients prescribed low-dose aspirin (less than or equal to 325 mg/day) who are advised of the associated GI bleeding risks.

Non-selective non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with a non-selective NSAID who have risk factors for GI bleeding and who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who are NOT treated with a low-dose aspirin, have risk factors for GI bleeding and are prescribed an NSAID who receive either a non-selective NSAID plus a gastroprotective agent (proton pump inhibitor [PPI] or misoprostol) or a COX-2-selective NSAID.

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who take coumadin and are prescribed an NSAID who receive either a cyclooxygenase 2 (COX-2)-selective NSAID or a nonacetylated salicylate.

Non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients prescribed an NSAID (non selective or selective) who are advised of the associated GI bleeding and renal risks with the GI risks documented.

Osteoarthritis: percentage of overweight patients (as defined by body mass index of greater than or equal to 27 kg/m2) who are advised to lose weight annually to prevent incident knee or hip osteoarthritis.

Osteoarthritis: percentage of patients beginning drug treatment for "joint pain," "arthritis," or "arthralgia" for whom there is documentation that the affected joint was examined.

Osteoarthritis: percentage of patients with a diagnosis of osteoarthritis and reporting difficulties with non-ambulatory activities of daily living whose functional ability with problem tasks are assessed for need of non-ambulatory assistive devices to aid with problem tasks.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip and reporting difficulty walking to accomplish activities of daily living for greater than 3 months whose walking ability is assessed for need of ambulatory assistive devices.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who are prescribed an exercise program.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who receive or who are recommended patient education.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual functional assessment.

Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual pain assessment.

Osteoarthritis: percentage of patients with hip or knee osteoarthritis and worsening complaints accompanied by a progressive decrease in activities and no previous radiographs during the preceding 3 months for whom a knee or hip radiograph is performed within 3 months.

Osteoarthritis: percentage of patients with osteoarthritis for whom oral pharmacologic therapy is changed from acetaminophen to a different oral agent with evidence that they have had a trial of maximum-dose acetaminophen (suitable for age and comorbidities).

Osteoarthritis: percentage of patients with osteoarthritis pain of mild or moderate severity for whom acetaminophen is the first drug used for initial nonnarcotic pharmacologic therapy to aid with problem tasks.

Osteoarthritis: percentage of patients with severe symptomatic osteoarthritis of the knee or hip who have failed to respond to nonpharmacologic and pharmacologic therapy who are referred to an orthopedic surgeon.

Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who are overweight (as defined by body mass index of greater than or equal to 27 kg/m2) and who are advised to lose weight to reduce symptoms of osteoarthritis.

Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who have been overweight (as defined by body mass index of greater than or equal to 27 kg/m2) for more than 3 years who are referred to a weight loss program.

Rheumatoid arthritis: percentage of female patients of childbearing age who are newly started on any of the following disease-modifying antirheumatic drugs (DMARDs): methotrexate, cyclophosphamide, azathioprine, sulfasalazine, chlorambucil, D-penicillamine, hydroxychloroquine, gold, etanercept, infliximab, leflunomide for whom a discussion with the patient about the teratogenic risks of these drugs and about contraception is documented.

Rheumatoid arthritis: percentage of patients being treated with methotrexate (MTX) who have elevations in serum transaminase levels above two times the upper range of normal for the laboratory two or more times over a three month period for whom non-steroidal anti-inflammatory drug (NSAID) or MTX dose reduction or discontinuation is documented within one month of the second abnormal laboratory result.

Rheumatoid arthritis: percentage of patients being treated with methotrexate for whom folate supplementation is given.

Rheumatoid arthritis: percentage of patients in the third trimester of pregnancy for whom non-steroidal anti-inflammatory drugs (NSAIDs) (selective and non-selective) and aspirin are not used.

Rheumatoid arthritis: percentage of patients newly prescribed acetaminophen for whom the risk versus benefits of this drug are discussed.

Rheumatoid arthritis: percentage of patients newly prescribed any of the following drugs: non-steroidal anti-inflammatory drugs (NSAIDs) (selective or non-selective), disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, or narcotics for whom a discussion with the patient about the risks versus benefits of the chosen therapy is documented.

Rheumatoid arthritis: percentage of patients on immunosuppressive therapy for whom there is evidence that the following vaccines have been given: influenza (annually), pneumococcal, meningococcal, haemophilus B, hepatitis B, and tetanus.

Rheumatoid arthritis: percentage of patients receiving greater than or equal to 10 mg per day of prednisone (or equivalent) for greater than six months with no documentation of worsening disease for whom there is documentation at some point during the treatment course that a steroid taper was attempted or a disease-modifying antirheumatic drug (DMARD) dose was increased.

Rheumatoid arthritis: percentage of patients receiving immunosuppressants and/or steroid therapy (greater than 10 mg per day prednisone equivalent for greater than two weeks) for whom live/oral polio, live typhoid, yellow fever, measles, mumps, rubella (MMR), bacille Calmette-Guerin (BCG) vaccine are not used.

Rheumatoid arthritis: percentage of patients referred to a physician for a new diagnosis of rheumatoid arthritis who are seen by the physician within 3 months.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis (RA) for whom baseline x-rays of the hands or feet are performed within 3 months of the initial diagnosis and every 3 years.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis for whom each of the following are documented within 3 months of diagnosis and at appropriate time intervals thereafter: a joint examination of three or more joint areas, functional status, disease activity (presence/absence of synovitis), acute phase reactant (defined by erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) and pain (by visual analog scale [VAS] or other mechanism).

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties performing tasks involving use of their hands and wrists either because of stiffness or pain for whom functional ability with their hands and wrists is assessed for need of hand or wrist splints (orthoses).

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties with activities of daily living either because of stiffness or pain for whom functional ability with the compliant tasks is assessed for need of assistive devices to aid with compliant tasks.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulty with walking either because of stiffness, pain or instability for whom walking ability is assessed for need for ambulatory assistive devices including a cane, insoles, and orthotics.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis, no contraindications to exercise and who are physically and mentally able to exercise for whom a directed or supervised muscle strengthening or aerobic exercise program has been prescribed at least once and reviewed at least once per year.

Rheumatoid arthritis: percentage of patients with an established diagnosis of rheumatoid arthritis (RA) whose RA is evaluated by a physician at least annually.

Rheumatoid arthritis: percentage of patients with an established diagnosis of sero-positive rheumatoid arthritis (RA), or RA and synovitis or RA and radiographic erosions who are treated with a disease-modifying antirheumatic drug (DMARD) unless contraindication to DMARD is documented.

Rheumatoid arthritis: percentage of patients with established treatment with a disease-modifying antirheumatic drug (DMARD) or glucocorticoids for whom monitoring for drug toxicity is performed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis and osteoporosis treated with oral or parenteral steroids for whom antiresorptive therapy is prescribed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis started on prednisone greater than or equal to 10 mgs daily, (or other steroid equivalent) and who continue on prednisone for more than three months for whom 1,500 mg calcium and 400 international units (IUs) per day of Vitamin D are prescribed and antiresorptive therapy is discussed with the patient.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are being treated with a disease-modifying antirheumatic drug (DMARD) and report worsening of symptoms over a six-month period of time and have evidence of active disease (synovitis) for whom one of the following are done: dose or route of DMARD administration is changed, DMARD is changed, an additional DMARD is added, or dose of glucocorticoids is started or increased.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are newly prescribed a disease-modifying antirheumatic drug (DMARD) for whom appropriate baseline studies are documented within an appropriate period of time from the original prescription.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have joint pain, joint instability, or tendon rupture affecting the upper extremity or the foot or ankle, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to a surgeon is offered unless contraindication to surgery is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have severe pain of the hips or knees, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to an orthopedic surgeon is offered unless contraindication to surgery is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have surgery requiring general anesthesia for whom there is management or documentation of the risk of atlanto-axial instability.

Rheumatoid arthritis: percentage of pregnant patients for whom methotrexate and leflunomide are not used.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for developing renal insufficiency for whom serum creatinine is assessed at baseline and at least once in the first year following initiation of therapy.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for GI bleeding for whom a complete blood count is performed at baseline and during the first year after initiating therapy.

Renal Physicians Association(47)

Advanced chronic kidney disease (CKD): percent of patients on a phosphate binder with iPTH measured within the last 3 months.

Advanced chronic kidney disease (CKD): percent of patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).

Advanced chronic kidney disease (CKD): percent of patients on lipid lowering treatment.

Advanced chronic kidney disease (CKD): percent of patients prescribed elemental calcium.

Advanced chronic kidney disease (CKD): percent of patients prescribed vitamin D2.

Advanced chronic kidney disease (CKD): percent of patients prescribed with calcitriol, alfacalcidol, or vitamin D analogues.

Advanced chronic kidney disease (CKD): percent of patients referred for surgery for construction of an arteriovenous (AV) fistula on index date.

Advanced chronic kidney disease (CKD): percent of patients referred to vocational rehabilitation center.

Advanced chronic kidney disease (CKD): percent of patients screened for dyslipidemia within 1 year.

Advanced chronic kidney disease (CKD): percent of patients treated with an erythropoietin or analogue.

Advanced chronic kidney disease (CKD): percent of patients treated with erythropoietin analogue to a hemoglobin (Hb) of 12 g/dL in women and 13 g/dL in men.

Advanced chronic kidney disease (CKD): percent of patients who are anemic, iron deficient and on iron therapy.

Advanced chronic kidney disease (CKD): percent of patients who have been referred for a transplant evaluation.

Advanced chronic kidney disease (CKD): percent of patients with 25(OH) vit D levels measured.

Advanced chronic kidney disease (CKD): percent of patients with anemia work-up.

Advanced chronic kidney disease (CKD): percent of patients with antihypertensive therapy intensified.

Advanced chronic kidney disease (CKD): percent of patients with blood pressure checked at every erythropoietin or analogue dose.

Advanced chronic kidney disease (CKD): percent of patients with blood pressure checked at least once within the last 3 months.

Advanced chronic kidney disease (CKD): percent of patients with blood pressure less than 130/80 mmHg and are receiving erythropoietin or analogue.

Advanced chronic kidney disease (CKD): percent of patients with blood pressure less than 130/80 mmHg on index date.

Advanced chronic kidney disease (CKD): percent of patients with documentation about counseling for increasing physical activity.

Advanced chronic kidney disease (CKD): percent of patients with documentation regarding discussion of renal replacement therapy (RRT) modalities.

Advanced chronic kidney disease (CKD): percent of patients with documentation that education was provided.

Advanced chronic kidney disease (CKD): percent of patients with hemoglobin measured at least every 3 months.

Advanced chronic kidney disease (CKD): percent of patients with iPTH greater than 100 pg/mL (or greater than 1.5 times the upper limit of normal for each assay used) and/or phosphorus greater than 4.5 mg/dL and are prescribed a low phosphorus diet for 1 month.

Advanced chronic kidney disease (CKD): percent of patients with iPTH greater than 100 pg/mL (or greater than 1.5 times the upper limit of normal for each assay used).

Advanced chronic kidney disease (CKD): percent of patients with low-density lipoprotein (LDL) less than 100 mg/dL.

Advanced chronic kidney disease (CKD): percent of patients with measurement of body weight and serum albumin within the last 3 months.

Advanced chronic kidney disease (CKD): percent of patients with one measurement of iPTH.

Advanced chronic kidney disease (CKD): percent of patients with phosphorus greater than 4.5 mg/dL after a low phosphorus diet for one month, now on a phosphate binder.

Advanced chronic kidney disease (CKD): percent of patients with phosphorus greater than 4.5 mg/dL.

Advanced chronic kidney disease (CKD): percent of patients with qualified nutritional counseling.

Advanced chronic kidney disease (CKD): percent of patients with serum bicarbonate greater than or equal to 22 mmol/L.

Advanced chronic kidney disease (CKD): percent of patients with serum bicarbonate measured within the last 3 months.

Advanced chronic kidney disease (CKD): percent of patients with serum calcium and phosphorus measured within the last 3 months.

Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile.

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February).

Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period.

Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V greater than or equal to 1.2 OR patients have a Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.

End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD who are receiving dialysis have a Hgb greater than or equal to 11g/dL OR have a Hgb less than 11g/dL with a documented plan of care for anemia.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the flu season (September through February).

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula OR patients who are referred for an AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis with a permanent catheter who are referred for evaluation for AV fistula at least once during the 12 month reporting period.

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times during the 12 month reporting period.

STABLE Project National Coordinating Council(17)

Bipolar disorder: percentage of patients with Bipolar I Disorder with depressive symptoms and behaviors who have evidence of use of a mood stabilizing or antimanic agent during the first 12 weeks of pharmacotherapy treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their level-of-functioning in response to treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are provided with education and information about their illness and treatment within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms twice within the first 24 weeks of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who receive at least one screening for hyperglycemia within the initial 16 weeks of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who received at least one assessment for hyperlipidemia within the initial 16 week period of treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with lithium who have evidence of a lithium serum medication level with 12 weeks of beginning treatment.

Bipolar disorder: the percentage of patients diagnosed with bipolar disorder who receive an initial assessment that considers the risk of suicide.

Bipolar disorder: the percentage of patients with bipolar disorder who receive a recommendation for an adjunctive psychosocial intervention, including evidence-based therapies, within 12 weeks of initiating treatment.

Bipolar disorder: the percentage of patients with bipolar disorder who receive an initial assessment that considers alcohol and chemical substance use.

Bipolar disorder: the percentage of patients with bipolar disorder who were monitored for weight gain during initial 12 week period of treatment.

Bipolar disorder: the percentage of patients with Bipolar I Disorder symptoms and behaviors who received monotherapy with an antidepressant agent during the first 12 weeks of treatment.

Bipolar disorder: the percentage of patients with Bipolar I Disorder with mania/hypomania, mixed or cycling symptoms and behaviors who have evidence of use of pharmacotherapy agent with antimanic properties during the first 12 weeks of treatment.

Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers alcohol and chemical substance use.

Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers the risk of suicide.

Depression: the percentage of patients presenting with depression who were assessed, prior to the initiation of treatment, for the presence of prior or current symptoms and/or behaviors associated with mania or hypomania.

State of Wisconsin, Department of Health and Family Services(82)

Ambulatory care management of diabetes: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS SSI). [NQMC Update Pending]

Ambulatory care management of diabetes: percent of patients with at least one lipid profile test in the look-back period (MEDDIC-MS SSI). [NQMC Update Pending]

Ambulatory diabetes care: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS). [NQMC Update Pending]

Ambulatory diabetes care: percent of patients with at least one lipid profile test in the look-back period (MEDDIC-MS). [NQMC Update Pending]

Asthma care: number of enrollees with a diagnosis of asthma (MEDDIC-MS). [NQMC Update Pending]

Asthma care: percent of enrollees with a diagnosis of asthma (MEDDIC-MS SSI). [NQMC Update Pending]

Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS SSI). [NQMC Update Pending]

Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS). [NQMC Update Pending]

Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS SSI). [NQMC Update Pending]

Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS). [NQMC Update Pending]

Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 17 and 28 months (MEDDIC-MS). [NQMC Update Pending]

Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 6 and 16 months (MEDDIC-MS). [NQMC Update Pending]

Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS SSI). [NQMC Update Pending]

Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS). [NQMC Update Pending]

Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC MS). [NQMC Update Pending]

Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC-MS SSI). [NQMC Update Pending]

Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS SSI). [NQMC Update Pending]

Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS). [NQMC Update Pending]

Cervical cancer detection: percent of women diagnosed with cervical/uterine malignancy among those screened (MEDDIC-MS SSI). [NQMC Update Pending]

Cervical cancer detection: percent of women diagnosed with cervical/uterine pre-malignant or malignant lesions among those screened (MEDDIC-MS). [NQMC Update Pending]

Cervical cancer detection: percent of women diagnosed with human papillomavirus (HPV) detected among those screened (MEDDIC-MS SSI). [NQMC Update Pending]

Cervical cancer detection: percent of women with human papillomavirus (HPV) detected among those screened (MEDDIC-MS). [NQMC Update Pending]

Child health: percent of children who received at least one non-EPSDT (non-HealthCheck), well-child examination or at least one non-EPSDT (non-HealthCheck), non-well-child encounter in the look-back period (MEDDIC-MS). [NQMC Update Pending]

Childhood immunizations (full coverage): percent of enrolled children who received all of the following by the measure end date: four DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 4 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR vaccination, one varicella (VZV) vaccination, three H influenza type B (Hib) vaccinations, three hepatitis B vaccinations (MEDDIC-MS). [NQMC Update Pending]

Childhood immunizations (substantial coverage): percent of enrolled children who received all of the following by the measure end date: three DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 3 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR vaccination, two H influenza type B (Hib) vaccinations, two hepatitis B vaccinations (MEDDIC-MS). [NQMC Update Pending]

EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received at least one EPSDT (HealthCheck) examination in the look-back period (MEDDIC-MS). [NQMC Update Pending]

EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received seven or more, six, or five comprehensive HealthCheck examinations by the age of two years (MEDDIC-MS). [NQMC Update Pending]

General and specialty care: percent of enrollees receiving at least one encounter of care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS). [NQMC Update Pending]

General and specialty care: percent of enrollees receiving care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS SSI). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS SSI). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS SSI). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS SSI). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS SSI). [NQMC Update Pending]

General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all inpatient hospitalizations for maternity-related diagnoses (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS SSI). [NQMC Update Pending]

Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all inpatient psychiatric stays (MEDDIC-MS SSI). [NQMC Update Pending]

Inpatient care: all inpatient psychiatric stays (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all inpatient stays for hospice, rehabilitation and respite care (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all inpatient stays for hospice, rehabilitation, and respite care (MEDDIC-MS SSI). [NQMC Update Pending]

Inpatient care: all inpatient substance abuse stays (MEDDIC-MS SSI). [NQMC Update Pending]

Inpatient care: all inpatient substance abuse stays (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all newborn care provided from birth to discharge home (MEDDIC-MS). [NQMC Update Pending]

Inpatient care: all surgical stays (MEDDIC-MS SSI). [NQMC Update Pending]

Inpatient care: all surgical stays (MEDDIC-MS). [NQMC Update Pending]

Maternity care: percent of enrollees who received prenatal care coordination (MEDDIC-MS). [NQMC Update Pending]

Maternity care: percent of enrollees who received substance abuse treatment services during the look-back period (MEDDIC-MS). [NQMC Update Pending]

Maternity care: percent of enrollees who received testing for HIV during the look-back period (MEDDIC-MS). [NQMC Update Pending]

Maternity care: percent of enrollees with delivery by Cesarean section (MEDDIC-MS). [NQMC Update Pending]

Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS SSI). [NQMC Update Pending]

Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS). [NQMC Update Pending]

Mental health: percent of enrollees diagnosed with non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment (MEDDIC-MS SSI). [NQMC Update Pending]

Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by mental health specialists (MEDDIC-MS). [NQMC Update Pending]

Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS). [NQMC Update Pending]

Obesity prevention and treatment: number of encounters with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).

Obesity prevention and treatment: percent of enrollees who had a non-surgical treatment of obesity (counseling, dietary therapy, exercise program, pharmacological intervention, etc.) with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).

Obesity prevention and treatment: percent of enrollees who had a screening and/or prevention encounter with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).

Obesity prevention and treatment: percent of enrollees who had a surgical treatment for obesity with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS). [NQMC Update Pending]

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS). [NQMC Update Pending]

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS). [NQMC Update Pending]

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a specialist mental health or substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). [NQMC Update Pending]

Preventive dental care: percent of enrollees age 18+ years who had at least one preventive dental service during the look-back period (MEDDIC-MS SSI). [NQMC Update Pending]

Preventive dental care: percent of patients age 21 years and older who have had at least one preventive dental service in the look-back period (MEDDIC-MS). [NQMC Update Pending]

Preventive dental care: percent of patients age 3 to 20 years who have had at least one preventive dental service in the look-back period (MEDDIC-MS). [NQMC Update Pending]

Substance abuse: percent of enrollees with substance abuse diagnosis receiving day/outpatient substance abuse treatment (MEDDIC-MS SSI). [NQMC Update Pending]

Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS). [NQMC Update Pending]

Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by substance abuse specialists (MEDDIC-MS). [NQMC Update Pending]

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had a pharmacological intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling and pharmacological intervention (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit and a counseling intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit with a counseling and pharmacological intervention (MEDDIC-MS).

The Endocrine Society(6)

Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.

Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.

Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.

Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.

Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.

Therapeutic Associates, Inc.(1)

Physical functional health status: average percent change in patient functional status from initial to discharge visit among patients receiving outpatient rehabilitation services.

University of Alabama at Birmingham(10)

Acetaminophen use: percentage of patients prescribed acetaminophen who have risk factors for liver disease AND the percentage of patients treated with high-dose (greater than or equal to 4 gm/day) acetaminophen who are advised of the associated risk of liver toxicity.

Cyclooxygenase 2 (COX-2)-selective non-steroidal anti-inflammatory drug (NSAID) use: percentage of patients treated with a COX-2-selective NSAID who are taking low-dose aspirin daily and have risk factors for GI bleeding who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Low-dose aspirin use: percentage of patients treated with a low-dose aspirin daily who have 2 or more risk factors for GI bleeding who are treated concomitantly with either misoprostol or proton pump inhibitor (PPI).

Low-dose aspirin: percentage of patients prescribed low-dose aspirin (less than or equal to 325 mg/day) who are advised of the associated GI bleeding risks.

Non-selective non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with a non-selective NSAID who have risk factors for GI bleeding and who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who are NOT treated with a low-dose aspirin, have risk factors for GI bleeding and are prescribed an NSAID who receive either a non-selective NSAID plus a gastroprotective agent (proton pump inhibitor [PPI] or misoprostol) or a COX-2-selective NSAID.

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who take coumadin and are prescribed an NSAID who receive either a cyclooxygenase 2 (COX-2)-selective NSAID or a nonacetylated salicylate.

Non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients prescribed an NSAID (non selective or selective) who are advised of the associated GI bleeding and renal risks with the GI risks documented.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for developing renal insufficiency for whom serum creatinine is assessed at baseline and at least once in the first year following initiation of therapy.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for GI bleeding for whom a complete blood count is performed at baseline and during the first year after initiating therapy.

Veterans Health Administration(50)

Acute coronary syndrome (ACS): percent of patients hospitalized for ACS with cardiac symptoms prior to or on arrival to the acute setting who had an ECG performed 15 minutes prior to arrival in acute setting or within 10 minutes after arrival.

Acute coronary syndrome (ACS): percent of patients hospitalized with ACS found to be high or moderate-high risk patients with cardiology involvement in care within 24 hours of acute arrival or if AMI as inpatient, within 24 hours of initial ECG or first positive troponin whichever is earlier.

Acute coronary syndrome (ACS): percent of patients with first troponin result returned within 60 minutes of order time.

Alcohol misuse: percent of patients screened for alcohol misuse with AUDIT-C who meet or exceed a threshold score of 5 who have timely brief alcohol counseling.

Appropriate screening: percent of eligible patients screened annually for alcohol misuse with AUDIT-C.

Breast cancer screening: percent of women age 40 to 49 screened for breast cancer in the past two years.

Breast cancer screening: percent of women age 40 to 69 screened for breast cancer in the past two years.

Breast cancer screening: percent of women age 50 to 69 screened in the past two years for breast cancer.

Cardiovascular: percent of patients discharged with AMI, CABG, PTCA (inpatient or outpatient), or with ischemic vascular disease who have had a full lipid panel in the past year.

Cervical cancer screening: percent of women age 21 to 64 screened for cervical cancer in the past three years.

Colon cancer screening: percent of patients receiving appropriate colorectal cancer screening.

Depression: percent of eligible patients screened annually for depression and if positive PHQ-2 or PHQ-9 result or affirmative response to Question 9, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.

Depression: percent of patients screened positive for depression symptoms with PHQ-2 or PHQ-9 or affirmative answer to Question 9 of the PHQ-9 who have timely triage.

Diabetes mellitus: percent of eligible patients with a diagnosis of diabetes mellitus having a nephropathy screening test during the past year or documented evidence of nephropathy.

Diabetes mellitus: percent of eligible patients with diabetes mellitus having a retinal exam by an Eye Care Specialist, timely, as indicated by disease.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus having HbA1c less than 7.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus having HbA1c testing performed during the past year.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus having hemoglobin A1c (HgbA1c) greater than 9 or not done during the past year.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus who have had a full lipid panel during the past year and the most recent LDL-C is less than 100 mg/dL.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus with blood pressure less than 140/90.

Diabetes mellitus: percent of patients with diabetes mellitus and blood pressure less than 130/80 mm Hg.

Diabetes mellitus: percent of patients with diabetes mellitus having full lipid panel in the past year.

Homeless: percent of eligible homeless veterans with an intake interview who receive timely MH or SUD specialty services.

Homeless: percent of homeless veterans entering a homeless program who receive timely MH or SUD specialty services.

Homeless: percent of homeless veterans entering a homeless residential program who receive timely primary care services.

Homeless: percent of veterans discharged from one of three types of homeless residential programs who receive timely MH or SUD specialty follow-up.

Hypertension: percent of eligible patients with an active diagnosis of hypertension whose most recent blood pressure recording was less than 140/90 mm Hg.

Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive mono-drug therapy where the regimen includes a thiazide diuretic.

Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive multi-drug therapy where the regimen includes a thiazide diuretic.

Infection rate reduction: number of central line associated bloodstream (CLAB) infections per 1,000 central line patient days.

Infection rate reduction: number of ventilator-associated pneumonia (VAP) infections per 1,000 ventilator days.

Influenza immunization: percent of applicable patients 65 years and older receiving influenza immunizations between September 1, 2007 and March 31, 2008 in accordance with defined VHA policy.

Influenza immunization: percent of applicable patients age 50 to 64 years receiving influenza immunizations between September 1, 2007 and March 31, 2008 in accordance with defined VHA policy.

Ischemic heart disease (IHD): percent of patients discharged with AMI, CABG, PTCA (inpatient or outpatient), or with ischemic vascular disease who have had a full lipid panel in the past year and LDL-C less than 100 on most recent test in past year.

Mental Health Intensive Case Management (MHICM): percent of psychosis patients projected as requiring MHICM who receive outpatient care in MHICM.

Mental health: percent of eligible patients screened annually for depression.

Mental health: percent of eligible patients screened at required intervals for PTSD.

Mental health: percent of patients beginning a new episode of treatment for substance use disorder (SUD) who maintain continuous treatment involvement for at least 90 days after qualifying date.

Mental health: the percentage of patients who were diagnosed with a new episode of depression and treated with antidepressant medication, and who had at least three follow-up practitioner contacts for medication management during the 84-day (12 week) acute treatment phase.

Mental health: the percentage of patients who were diagnosed with a new episode of depression, and treated with antidepressant medication, and who remained an antidepressant drugs for at least 84 treatment days (12 weeks) after the Index Prescription Date.

Pneumococcal immunization: percent of applicable patients receiving pneumococcal immunization.

Post-traumatic stress disorder (PTSD): percent of eligible patients screened at required intervals for PTSD and if positive PC-PTSD result, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.

Smoking cessation: percent of patients using tobacco who have been offered a referral to smoking cessation specialty program to assist with cessation within the past year.

Smoking cessation: percent of patients using tobacco who have been offered medications to assist with cessation.

Smoking cessation: percent of patients using tobacco who have been provided with brief counseling within the past year.

Veteran satisfaction: percent of patients reporting the overall quality of Veterans Administration (VA) ambulatory care as very good or excellent on the SHEP Outpatient Survey.

Veteran satisfaction: percent of patients reporting the overall quality of Veterans Administration (VA) inpatient care as very good or excellent on the SHEP Inpatient Survey.

Waiting times - clinic: percent of outpatients seen in primary care at the facility in the previous 24 months who answer 'yes' to the question, "Did you get an appointment when you wanted one?" on the SHEP survey.

Waiting times - clinic: percent of outpatients who have not been seen in primary care at the facility in the previous 24 months who answer 'yes' to the question, "Did you get an appointment when you wanted one?" on the SHEP survey.

Waiting times - provider: percent of outpatients who report waiting for a provider 20 minutes or less in the Survey of Healthcare Experiences of Patients (SHEP).

VHA, Inc.(19)

Intensive care unit (ICU) palliative care: percent of 4-hour intervals (on Day Zero and Day One of ICU admission) for which pain was assessed and documented.

Intensive care unit (ICU) palliative care: percent of 4-hour intervals (on Day Zero and Day One of ICU admission) for which the documented pain score was less than or equal to 3.

Intensive care unit (ICU) palliative ca