CAHPS Dental Plan Survey

• Dental plan members' experiences: adult dental plan members' ratings of their dental care.
• Dental plan members' experiences: adult dental plan members' ratings of their dental plan.
• Dental plan members' experiences: adult dental plan members' ratings of their regular dentist.
• Dental plan members' experiences: adult dental plan members' who reported how easy it was for them to find a dentist.
• Dental plan members' experiences: percentage of adult dental plan members who indicated how often they were satisfied with access to dental care.
• Dental plan members' experiences: percentage of adult dental plan members who indicated how often they were satisfied with care from dentists and staff.
• Dental plan members' experiences: percentage of adult dental plan members who indicated how often they were satisfied with dental plan costs and services.

CAHPS Home Health Care Survey

• Patients' Experiences: percentage of adult home health care patients who reported how often their home health care providers communicated well.
• Patients' Experiences: percentage of adult home health care patients who reported how often they were satisfied with their home health care provider's patient care.
• Patients' Experiences: percentage of adult home health care patients who reported whether their home health care providers addressed specific care issues related to pain and medication.
• Patients' Experiences: percentage of adult home health care patients who reported whether they would recommend this agency to their friends and family.
• Patients' Experiences: percentage of adult home health care patients' ratings of this agency's home health providers.

DrScore Survey

• Patients' satisfaction with care: patients' overall rating of their physician office.
• Patients' satisfaction with care: patients' overall rating of their physician.

Treatment Satisfaction Questionnaire for Medication (TSQM) Version II

• Medication satisfaction: mean scale score for the "Convenience" items on the Treatment Satisfaction Questionnaire for Medication.
• Medication satisfaction: mean scale score for the "Effectiveness" items on the Treatment Satisfaction Questionnaire for Medication.
• Medication satisfaction: mean scale score for the "Global Satisfaction" items on the Treatment Satisfaction Questionnaire for Medication.
• Medication satisfaction: mean scale score for the "Side Effects" items on the Treatment Satisfaction Questionnaire for Medication.

Australian Council on Healthcare Standards (ACHS) Equip Clinical Indicators

• 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.
• 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.
• 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.
• Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in femoro-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) (involving chest and donor incisions) procedures performed, 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 the donor incision site) in coronary artery bypass graft (CABG) (involving chest and donor incisions) 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 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 superficial incisional surgical site infections (SSIs) in femoro-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.

Quality and Outcomes Framework Indicators

• Asthma: the percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility.
• 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.
• Asthma: the percentage of patients with asthma who have had an asthma review in the previous 15 months.
• 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.
• Atrial fibrillation: the percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with electrocardiogram (ECG) or specialist confirmed diagnosis.
• Atrial fibrillation: the percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy.
• Atrial fibrillation: the practice can produce a register of patients with atrial fibrillation.
• Cancer: the percentage of patients with cancer diagnosed within the last 18 months who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis.
• 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.'
• Cardiovascular disease: the percentage of patients with a new diagnosis of hypertension recorded between the preceding 1 April to 31 March who had a face to face cardiovascular risk assessment at the outset of the diagnosis using an agreed risk assessment tool.
• Cardiovascular disease: the percentage of people diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet.
• Cervical screening: the practice has a protocol that is in line with national guidance and practice for the management of cervical screening, which includes staff training, management of patient call/recall, exception reporting and the regular monitoring of inadequate smear rates.
• Cervical screening: the practice has a system for informing all women of the results of cervical smears.
• Child health surveillance: does the practice offer child development checks at intervals that are consistent with national guidelines and policy?
• 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.
• Chronic kidney disease (CKD): the percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months.
• 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.
• Chronic kidney disease (CKD): the percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded).
• 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).
• Chronic obstructive pulmonary disease (COPD): the percentage of all patients with COPD diagnosed after 1 April 2008 in whom the diagnosis has been confirmed by post bronchodilator spirometry.
• Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using MRC dyspnoea score in the preceding 15 months.
• Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March.
• Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD with a record of FeV1 in the previous 15 months.
• Chronic obstructive pulmonary disease (COPD): the practice can produce a register of patients with COPD.
• Contraception: the percentage of women prescribed emergency hormonal contraception at least once in the year by the practice who have received information from the practice about long acting reversible methods of contraception at the time of, or within one month of, the prescription.
• Contraception: the percentage of women who have been prescribed an oral or patch contraceptive method who have also received information from the practice about long acting reversible methods of contraception in the previous 15 months.
• Contraception: the practice can produce a register of women who have been prescribed any method of contraception at least once in the last year, or other appropriate interval, e.g., last 5 years for an IUS.
• 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.
• Coronary heart disease: the percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 mm Hg or less.
• 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).
• 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.
• Coronary heart disease: the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in previous 15 months) is 5 mmol/l or less.
• Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months.
• Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months.
• 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).
• 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.
• Coronary heart disease: the practice can produce a register of patients with coronary heart disease.
• Dementia: the percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months.
• Dementia: the practice can produce a register of patients diagnosed with dementia.
• Depression: the percentage of patients on the diabetes register and/or coronary heart disease (CHD) register for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions.
• Depression: the percentage of patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March who have had a further assessment of severity 5-12 weeks (inclusive) after the initial recording of the assessment of severity.
• Depression: the percentage of patients with a new diagnosis of depression, recorded between the preceding 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.
• Diabetes mellitus: the percentage of patients with diabetes in who the last HbA1c is 9 or less (or equivalent test/reference rage depending on local laboratory) in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes in whom the last blood pressure is 145/85 or less.
• Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 7 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 8 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months.
• 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.
• Diabetes mellitus: the percentage of patients with diabetes who have a record of HbA1c or equivalent in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months and the percentage of patients with proteinuria.
• Diabetes mellitus: the percentage of patients with diabetes who have a record of retinal screening in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March.
• Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less.
• Diabetes mellitus: the percentage of patients with diabetes whose notes record body mass index (BMI) in the previous 15 months.
• 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).
• Diabetes mellitus: the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months.
• Diabetes mellitus: the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months.
• 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.
• Education: all practice-employed nurses have personal learning plans which have been reviewed at annual appraisal.
• Education: The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team.
• Education: the practice has undertaken a minimum of three significant event reviews within the last year.
• Education: the practice has undertaken a minimum of twelve significant event reviews in the past 3 years which could include: any death occurring in the practice premises; new cancer diagnoses; deaths where terminal care has taken place at home; any suicides; admissions under the Mental Health Act; child protection cases; medication errors; a significant event occurring when a patient may have been subjected to harm, had the circumstance/outcome been different (near miss).
• Education: there is a record of all practice-employed clinical staff having attended training/updating in basic life support skills in the preceding 18 months.
• Education: there is a record of all practice-employed staff having attended training/updating in basic life support skills in the preceding 36 months.
• 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.
• 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.
• 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.
• Epilepsy: the practice can produce a register of patients age 18 years and over receiving drug treatment for epilepsy.
• Heart failure: the percentage of patients with a current diagnosis of heart failure due to LDV who are currently treated with ACE inhibitor or ARB, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers.
• 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.
• 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.
• Heart failure: the practice can produce a register of patients with heart failure.
• Hypertension: the percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less.
• Hypertension: the percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months.
• Hypertension: the practice can produce a register of patients with established hypertension.
• Hypothyroidism: the percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months.
• Hypothyroidism: the practice can produce a register of patients with hypothyroidism.
• Information: if a patient is removed from a practice’s list, the practice provides an explanation of the reasons in writing to the patient and information on how to find a new practice, unless it is perceived that such an action would result in a violent response by the patient.
• Information: the practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy.
• Learning disabilities: the practice can produce a register or patients aged 18 and over with learning disabilities.
• Management: individual healthcare professionals have access to information on local procedures relating to Child Protection.
• Management: the Hepatitis B status of all doctors and relevant practice-employed staff is recorded and immunisation recommended if required in accordance with national guidance.
• Management: the practice has a protocol for the identification of carers and a mechanism for the referral of carers for social services assessment.
• Management: The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment including: a defined responsible person; clear recording; systematic pre-planned schedules; reporting of faults.
• Management: the practice offers a range of appointment times to patients, which as a minimum should include morning and afternoon appointments five mornings and four afternoons per week, except where agreed with the PCO.
• Maternity services: does the practice offer ante-natal care and screening according to current local guidelines?
• Medicines: percentage of patients being prescribed four or more repeat medicines for whom a medication review is recorded in the notes in the preceding 15 months.
• Medicines: percentage of patients being prescribed repeat medicines for whom a medication review is recorded in the notes in the preceding 15 months.
• Medicines: the number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less (excluding weekends and bank/local holidays).
• Medicines: the number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays).
• Medicines: the practice meets the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing.
• Medicines: the practice meets the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change.
• Medicines: the practice possesses the equipment and in-date emergency drugs to treat anaphylaxis.
• Medicines: there is a system for checking the expiry dates of emergency drugs on at least an annual basis.
• Mental health: the percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months.
• Mental health: the percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months.
• 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.
• 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.
• Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months.
• Mental health: the practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses.
• 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.
• Palliative care: the practice has a complete register available of all patients in need of palliative care/support irrespective of age.
• Palliative care: the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.
• Patients' experience: the percent of routine booked appointments with doctors in the practice that are not less than 10 minutes (8 minutes for practices with only an open surgery system).
• Patients' experience: the percentage of patients who, in the appropriate national survey, indicate that they were able to book an appointment with a GP more than 2 days ahead.
• Patients' experience: the percentage of patients who, in the appropriate national survey, indicate that they were able to obtain a consultation with a GP or appropriate health care professional within 2 working days (in Wales this will be within 24 hours).
• Records: 80% of newly registered patients have had their notes summarised within 8 weeks of receipt by the practice.
• Records: ethnic origin is recorded for 100% of new registrations.
• Records: for repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004).
• Records: the blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients.
• Records: the blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 80% of patients.
• Records: the percentage of patients aged over 15 years whose notes record smoking status in the past 27 months (payment stages 40 – 90%).
• Records: the practice has a system for transferring and acting on information about patients seen by other doctors out of hours.
• Records: the practice has up-to-date clinical summaries in at least 60% of patient records.
• Records: the practice has up-to-date clinical summaries in at least 70% of patient records.
• Records: the practice has up-to-date clinical summaries in at least 80% of patient records.
• Records: there is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded.
• Records: there is a system to alert the out-of-hours service or duty doctor to patients dying at home.
• 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), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses 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.
• 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), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the previous 15 months.
• Stroke and transient ischaemic attack (TIA): the percentage of new patients with a stroke or TIA who have been referred for further investigation.
• 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.
• 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).
• 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.
• 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.
• 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.
• 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.
• Stroke and transient ischaemic attack (TIA): the practice can produce a register of patients with stroke or TIA.

Health Indicators 2009

• Acute myocardial infarction (AMI): risk-adjusted rate of all cause in-hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of AMI.
• Acute myocardial infarction (AMI): risk-adjusted rate of unplanned readmission following discharge for AMI.
• Acute myocardial infarction: age-standardized rate of new AMI events admitted to an acute care hospital, per 100,000 population age 20 and older.
• Ambulatory care sensitive conditions: age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years.
• Asthma: risk-adjusted rate of unplanned readmission following discharge for asthma.
• Caesarean section: proportion of women delivering babies in acute care hospital by Caesarean section.
• Cardiac revascularization: age-standardized rate of CABG surgery performed on inpatients in acute care hospitals or PCI performed on patients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over.
• Coronary artery bypass graft (CABG) surgery: age-standardized rate of CABG surgery performed on inpatients in acute care hospitals, per 100,000 population age 20 years and over.
• Hip fracture: age-standardized rate of new hip fractures admitted to an acute care hospital per 100,000 population age 65 and over.
• Hip fracture: risk adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges.
• Hip fracture: risk-adjusted proportion of hip fracture patients aged 65 years and older who underwent hip fracture surgery in an acute care hospital on the day of admission or the next day.
• Hip fracture: risk-adjusted proportion of hip fracture patients aged 65 years and older who underwent hip fracture surgery in an acute care hospital on the day of admission, the next day or the day after that.
• Hip replacement surgery: age-standardized rate of unilateral or bilateral hip replacement surgery performed on inpatients in acute care hospitals per 100,000 population age 20 years and over.
• Hysterectomy: age-standardized rate of hysterectomy provided to patients in acute care hospitals or same-day surgery facilities, per 100,000 women age 20 years and over.
• Hysterectomy: risk-adjusted rate of unplanned readmission following discharge for hysterectomy.
• Inflow/outflow: ratio of the number of separations (discharges and deaths) from acute care/same day surgery facilities within a given region by the number of acute care/same day surgery separations generated by residents of that region.
• Injury: the age-standardized rate of acute care hospitalization due to injury resulting from the transfer of energy (excluding poisoning and other non-traumatic injuries), per 100,000 population.
• Knee replacement surgery: age-standardized rate of unilateral or bilateral knee replacement surgery performed on patients in acute care hospitals or same-day surgery facilities, per 100,000 population age 20 years and over.
• Percutaneous coronary interventions (PCI): age-standardized rate of PCI performed on inpatients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over.
• Physician to population ratio: total number of general physicians and family physicians per 100,000 population.
• Physician to population ratio: total number of specialist physicians per 100,000 population.
• Prostatectomy: risk-adjusted rate of unplanned readmission following discharge for prostatectomy.
• Stroke: age-standardized rate of new stroke events admitted to an acute care hospital, per 100,000 population age 20 and older.
• Stroke: risk-adjusted rate of all cause in-hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of stroke.

Dialysis Facility Compare (DFC) Measures

• End stage renal disease (ESRD): percentage of eligible Medicare hemodialysis patients at the facility during the calendar year with a median URR value of 65% or higher.
• End stage renal disease (ESRD): percentage of Hemodialysis and Peritoneal Dialysis patients, with ESRD greater than or equal to 3 months, who have a mean Hemoglobin greater than 12 g/dL for a 12 month reporting period, treated with ESA.
• End stage renal disease (ESRD): percentage of Hemodialysis and Peritoneal Dialysis patients, with ESRD greater than or equal to 3 months, who have a mean Hemoglobin less than 10 g/dL for a 12 month reporting period, treated with ESA.
• End stage renal disease (ESRD): risk-adjusted standardized mortality ratio for dialysis facility patients.

ESRD Clinical Performance Measures

• End stage renal disease (ESRD): percentage of adult hemodialysis and peritoneal dialysis patients, with ESRD greater than 3 months, and who had Hb values reported for at least 2 of the 3 study months who have a mean Hemoglobin less than 10.0 g/dL for a 3 month reporting period, irrespective of ESA use.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) HD patients in the sample for analyses with documented monthly adequacy measurements (spKt/V) or its components in the calendar month.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) hemodialysis and peritoneal dialysis patients prescribed an ESA at any time during the study period or who have a Hb less than 11.0 g/dL in at least one month of the study period for whom serum ferritin concentration AND either percent transferrin saturation or reticulocyte Hb content (CHr) are measured at least once during the study period for in-center hemodialysis patients, and at least twice during the study period for peritoneal dialysis patients and home hemodialysis patients.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) hemodialysis and peritoneal dialysis patients, with ESRD greater than 3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb less than 10.0 g/dL for a 3 month study period, irrespective of ESA use.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) in-center HD patients in the sample for analyses for whom delivered HD dose was calculated using UKM or Daugirdas II during the study period and for whom the frequency of HD per week is specified.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) patients in the sample for analysis who have been on hemodialysis for 6 months or more and dialyzing thrice weekly whose average delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V greater than or equal to 1.2 during the study period.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 day or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V greater than or equal to 1.2 during the study period.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum calcium measured at least once within a month.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum phosphorus measured at least once within a month.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) peritoneal dialysis patients whose delivered peritoneal dialysis dose was a weekly Kt/V urea of at least 1.7 (dialytic + residual) during the four month study period.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) peritoneal dialysis patients with total solute clearance for urea (endogenous residual renal urea clearance & dialytic) measured at least once in a four month time period.
• End stage renal disease (ESRD): percentage of all adult (greater or equal to 18 years old) peritoneal dialysis patients with weekly Kt/V urea (endogenous residual renal urea clearance & dialytic) calculated in a standard way.
• End stage renal disease (ESRD): percentage of patients on maintenance hemodialysis during the last HD treatment of the month using an autogenous AV fistula with two needles.
• End stage renal disease (ESRD): percentage of patients who are dialyzed with a chronic catheter (90 days or more) prior to the last hemodialysis session during the study period.

National Hospital Inpatient Quality Measures

• Acute myocardial infarction (AMI): 30-day mortality rate.
• Acute myocardial infarction (AMI): thirty-day all-cause risk standardized readmission rate following AMI hospitalization.
• 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.
• 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.
• Heart failure (HF): 30-day mortality rate.
• Heart failure (HF): thirty-day all-cause risk standardized readmission rate following HF hospitalization.
• Pneumonia (PN): 30-day mortality rate.
• 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.
• Pneumonia: thirty-day all-cause risk standardized readmission rate following pneumonia hospitalization.

National Hospital Inpatient Quality Measures

• 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.
• Acute myocardial infarction: median time from hospital arrival to primary PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time.
• 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.
• Acute myocardial infarction: percent of patients receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.
• Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay.
• 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.
• Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge.
• Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.
• Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge.
• 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.
• 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.
• Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay.
• 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.
• 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.
• 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.
• Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital.
• 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.
• Pneumonia: percent of patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics.
• Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.
• Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose.
• Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines.
• Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision.
• Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
• Surgical care improvement project: percent of surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8 degrees Fahrenheit/36 degrees Celsius recorded within the 20 minutes immediately prior to or the fifteen minutes immediately after anesthesia end time.
• Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period.
• Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.
• Surgical care improvement project: percent of surgery patients with appropriate hair removal.
• Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time.
• Surgical care improvement project: percent of surgical patients with urinary catheter removed on postoperative day 1 or postoperative day 2 with the day of surgery being day zero.
• Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnosis testing order date.
• Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE that are discharged to home, to home with home health or home hospice on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about potential for adverse drug reactions/interactions.
• Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy.
• Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received intravenous unfractionated heparin therapy doses AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
• Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
• Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

HealthPartners Clinical Indicators

• Cervical cancer screening: percentage of women ages 21 years and older in the measurement year screened in accordance with evidence-based standards.
• Depression: percentage of members ages 18 years and older diagnosed with a new episode of depression, treated with antidepressant medication and optimally managed.
• 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.

Diagnosis and Initial Treatment of Ischemic Stroke

• Diagnosis and initial treatment of ischemic stroke: percentage of patients who were screened for dysphagia before taking any food, fluids or medication (including aspirin) by mouth.

Major Depression in Adults in Primary Care Measures

• 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 Measures

• 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.

Prevention and Management of Obesity (Mature Adolescents and Adults) Measures

• Prevention and management of obesity (mature adolescents and adults): percentage of patients with a documented elevated Body Mass Index (BMI) who receive education and counseling for weight loss strategies, which include nutrition, physical activity, lifestyle changes, medication therapy and/or surgery.

Routine Prenatal Care Measures

• New Routine prenatal care: percentage of all identified preterm birth (PTB) modifiable risk factors assessed that receive an intervention.
• New Routine prenatal care: percentage of pregnant women who report to have received counseling and education by the 28th week visit.
• New 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 Measures

• Stable coronary artery disease (CAD): percentage of patients with stable CAD who have aspirin use documented in the medical record.

National Hospital Inpatient Quality Measures

• Acute myocardial infarction: percent of patients who expired during hospital stay.
• Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization.
• Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization.
• 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.
• Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital.
• 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.
• 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.
• Stroke: percent of acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at the hospital within 3 hours (less than or equal to 180 minutes) of time last known well.
• Stroke: percent of ischemic and hemorrhagic stroke patients who have received venous thromboembolism (VTE) prophylaxis or who have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.
• Stroke: percent of ischemic or hemorrhage stroke patients who were assessed for rehabilitation services.
• Stroke: percent of ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during their hospital stay addressing all five specified education categories.
• Stroke: percent of ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
• Stroke: percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
• Stroke: percent of ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
• Stroke: percent of ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival, who are prescribed a statin medication at hospital discharge.

HEDIS® 2010: Health Plan Employer Data and Information Set

• Acute myocardial infarction (AMI): percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.
• Adolescent well-care visits: percentage of members 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.
• Adult body mass index (BMI) assessment: percentage of members 18 to 74 years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior to the measurement year.
• Adults' access to preventive/ambulatory health services: percentage of members 20 years and older who had an ambulatory or preventive care visit.
• Ambulatory care: summary of utilization of ambulatory care in the following categories: outpatient visits, emergency department visits, ambulatory surgery/procedures, and observation room stays.
• 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.
• 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.
• 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.
• 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.
• Antibiotic utilization: summary of outpatient utilization of antibiotic prescriptions during the measurement year, stratified by age and gender.
• Antidepressant medication management (effective acute phase treatment): percentage of members who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for at least 84 days (12 weeks).
• Antidepressant medication management (effective continuation phase treatment): percentage of members who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for at least 180 days (6 months).
• 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.
• 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.
• Aspirin use: percentage of men 45 through 64 years who have at least one risk factor for cardiovascular risk; women 55 through 79 years who have at least two risk factors for CVD; all men 65-79 years who currently report taking aspirin.
• Aspirin use: percentage of women 55 through 79 years and men 45 through 79 years who were counseled about the risk and benefits of aspirin.
• Asthma: percentage of members 5 to 50 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.
• Attention-deficit/hyperactivity disorder (ADHD) (continuation and 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.
• 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.
• 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.
• 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.
• Care for older adults (COA): percentage of adults 65 years and older who had each of the following during the measurement year: advance care planning, medication review, functional status assessment and pain screening.
• 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.
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB) and one chicken pox vaccination (VZV) by their second birthday (combination #2).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV) and four pneumococcal conjugate (PCV) vaccinations by their second birthday (combination #3).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, and receive the required number of rotavirus (RV) vaccinations (two doses or three doses, depending on which vaccine is administered) by their second birthday (combination #5).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, and two hepatitis A (HepA) vaccinations by their second birthday (combination #4).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, and two influenza vaccinations by their second birthday (combination #6).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, receive the required number of rotavirus (RV) vaccinations (two doses or three doses, depending on which vaccine is administered), and two influenza vaccinations by their second birthday (combination #9).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, two hepatitis A (HepA) vaccinations, and two influenza vaccinations by their second birthday (combination #8).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, two hepatitis A (HepA) vaccinations, receive the required number of rotavirus (RV) vaccinations (two doses or three doses, depending on which vaccine is administered), and two influenza vaccinations by their second birthday (combination #10).
• Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectable polio virus (IPV), one measles, mumps, and rubella (MMR), two haemophilus influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccination (VZV), four pneumococcal conjugate (PCV) vaccinations, two hepatitis A vaccinations (HepA), and receive the required number of rotavirus (RV) vaccinations (two doses or three doses, depending on which vaccine is administered) by their second birthday (combination #7).
• Children and adolescents' access to primary care practitioners: percentage of members 12 months to 19 years of age who had a visit with a primary care practitioner.
• Chlamydia screening: percentage of women 15 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
• 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.
• Chronic obstructive pulmonary disease (COPD): percentage of members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.
• Colorectal cancer screening: percentage of adults 50 to 75 years of age who had appropriate screening for colorectal cancer.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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).
• 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% (controlled).
• 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 8.0% (controlled).
• 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.
• Dental care: percentage of members 2 through 21 years of age who had at least one dental visit during the measurement year.
• Engagement of alcohol and other drug (AOD) treatment: percentage of members who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
• 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.
• 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 falls or problems with balance or walking with their current practitioner.
• 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.
• Frequency of selected procedures: summary of utilization of seventeen frequently performed procedures.
• 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.
• Health plan members' experiences: percentage of adult health plan members who reported how often it was easy to get needed care.
• 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.
• Health plan members' experiences: percentage of adult health plan members who reported how often their health plans handled their claims quickly and correctly.
• 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.
• 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 able to find out from their health plan how much they would have to pay for a healthcare service or equipment and specific prescription medicines.
• Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan's customer service.
• 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.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often it was easy to get needed care for their child.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often it was easy to get prescription medicines for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often it was easy to get specialized services for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child got care quickly.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child's doctors communicated well.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often they were satisfied with their child's health plan customer service.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experience with shared decision making for their child.
• 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.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences with their children's personal doctor for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported whether they received assistance with coordination of care and services for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians who reported how often their child's personal doctor seemed informed and up-to-date about the care their child got from other doctors or health providers.
• Health plan members' experiences: percentage of parents or guardians who reported how often they and their child's doctor or other health provider talked about specific things they could do to prevent illness in their child.
• 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.
• Health plan members' satisfaction with care: adult health plan members' ratings of the specialist they saw most often.
• 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 doctor.
• Health plan members' satisfaction with care: parents' or guardians' ratings of the specialist their child saw most often.
• Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health care.
• Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health plan.
• Health plan members' satisfaction with care: parents' or guardians' ratings of their child's personal doctor.
• 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 140/90 mm Hg) during the measurement year.
• Identification of alcohol and other drug services: summary of the number and percentage of members with an alcohol and other drug (AOD) claim who received the following chemical dependency services during the measurement year: any services, inpatient, intensive outpatient or partial hospitalization, and outpatient or emergency department (ED).
• Immunization for Adolescents: percentage of enrolled adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.
• Influenza immunization: percentage of commercial 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.
• 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.
• 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.
• Inpatient utilization--general hospital/acute care: summary of utilization of acute inpatient care and services in the following categories: total inpatient, medicine, surgery, and maternity.
• Inpatient utilization--nonacute care: summary of utilization of nonacute inpatient care in hospice, nursing home, rehabilitation, skilled nursing facility (SNF), transitional care and respite.
• 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.
• 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.
• 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.
• Medication reconciliation post-discharge: percentage of discharges from January 1 to December 1 of the measurement year for members 65 years of age and older for whom medications were reconciled on or within 30 days of discharge.
• Mental health utilization: number and percentage of members receiving the following mental health services during the measurement year: any services, inpatient, intensive outpatient or partial hospitalization, and outpatient or emergency department (ED).
• 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.
• 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.
• 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.
• 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.
• Outpatient drug utilization: summary of outpatient utilization of drug prescriptions, stratified by age, during the measurement year.
• Pharmacotherapy management of COPD exacerbation: percentage of chronic obstructive pulmonary disease (COPD) exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to November 30 of the measurement year and who were dispensed a bronchodilator within 30 days of the event.
• Pharmacotherapy management of COPD exacerbation: percentage of chronic obstructive pulmonary disease (COPD) exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to November 30 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event.
• 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.
• 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.
• Pneumonia vaccination status: percentage of Medicare members 65 years of age and older who have ever received a pneumococcal vaccination.
• Postpartum care: percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
• 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.
• 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.
• 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.
• 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).
• 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 smoking cessation methods or strategies were recommended or discussed.
• 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.
• 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 smoking cessation medications were recommended or discussed.
• The Medicare Health Outcomes Survey: percentage of members whose health status was "better than expected," "the same as expected" or "worse than expected" at the end of a two-year period.
• 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.
• 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.
• 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.
• 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.
• Weight assessment and counseling for nutrition and physical activity for children and adolescents: percentage of members 2 to 17 years of age who had an outpatient visit with PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
• 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.
• 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.

End Result Outcome Measures

• Hospice and palliative care: percentage of discharged hospice patients who preferred not to be hospitalized during their hospice stay who were not hospitalized during their hospice stay.
• Hospice and palliative care: percentage of discharged hospice patients whose most recently recorded preference was to forgo cardiopulmonary resuscitation (CPR) who did not have CPR.
• Hospice and palliative care: percentage of patients with pain at the time of admission whose pain was brought to a comfortable level within 48 hours of their admission to the hospice program.

The Physician Consortium for Performance Improvement® Measurement Sets

• Care transition: percentage of patients, regardless of age, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of specified elements.
• Care transition: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.
• Care transition: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care, or their caregiver(s), who received a reconciled medication list at the time of discharge including, at minimum, medications in the specified categories.
• Care transition: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements.
• HIV/AIDS: percentage of patients aged 1-5 years of age with a diagnosis of HIV/AIDS and a CD4 cell count below 500 cells/mm3 or a CD4 percentage below 15% who were prescribed pneumocystic jiroveci pneumonia (PCP) prophylaxis within 3 months.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia and gonorrhea screenings were performed at least once since the diagnosis of HIV infection.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom Hepatitis C screening was performed at least once since the diagnosis of HIV infection, or for whom there is documented immunity.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom syphilis screening was performed during the measurement year.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who had at least two medical visits during the measurement year, with at least 60 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load below limits of quantification after at least 6 months of potent antiretroviral therapy OR whose viral load is not below limits of quantification after at least 6 months of potent antiretroviral therapy and has documentation of a plan of care.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened for high risk sexual behaviors at least once within 12 months.
• HIV/AIDS: percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened for injection drug use at least once within 12 months.
• HIV/AIDS: percentage of patients aged 2 years and older with a diagnosis of HIV/AIDS for whom a pneumococcal vaccine was administered or documented to have been previously received at least once since diagnosis of HIV infection.
• HIV/AIDS: percentage of patients aged 3 months and older with a diagnosis of HIV/AIDS for whom there was documentation that a tuberculosis (TB) screening test was performed and results interpreted at least once since the diagnosis of HIV infection.
• HIV/AIDS: percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom an influenza immunization was administered or documented to have been previously received during the current influenza season.
• HIV/AIDS: percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months.
• HIV/AIDS: percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom Hepatitis B screening was performed at least once since the diagnosis of HIV infection, or for whom there is documented immunity.
• HIV/AIDS: percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS who have ever received at least one injection of Hepatitis B vaccine, or who have documented immunity.
• HIV/AIDS: percentage of patients aged 6 weeks to 12 months with a diagnosis of HIV or who are HIV indeterminate who were prescribed Pneumocystic jiroveci pneumonia (PCP) prophylaxis.
• HIV/AIDS: percentage of patients aged 6 years and older with a diagnosis of HIV/AIDS and a CD4 cell count below 200 cells/mm3 who were prescribed pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months.
• HIV/AIDS: percentage of patients with a diagnosis of HIV/AIDS with at least two visit during the measurement year, with at least 60 days between each visit: aged 13 years and older who have a history of a nadir CD4+ count below 350/mm3; aged 13 years and older who have a history of an AIDS-defining illness, regardless of CD4+ count; or who are pregnant, regardless of CD4+ count or age, who were prescribed potent antiretroviral therapy.
• Obstructive sleep apnea: percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy.
• Obstructive sleep apnea: percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis.
• Obstructive sleep apnea: percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness.
• Obstructive sleep apnea: percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.
• Palliative and end of life care: percentage of patients with advanced chronic or serious life threatening illness 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 in the medical record.
• Palliative and end of life care: percentage of patients with advanced chronic or serious life threatening illnesses that are screened for dyspnea and diagnosed with moderate or severe dyspnea, who have a documented plan of care to manage dyspnea.
• Palliative and end of life care: percentage of patients with advanced chronic or serious life threatening illnesses that are screened for dyspnea.
• 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 patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within twelve months.
• Rheumatoid arthritis: percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity at least once within 12 months.
• Rheumatoid arthritis: percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.
• Rheumatoid arthritis: percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone greater than 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.
• Rheumatoid arthritis: percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying antirheumatic drug (DMARD).

Safe Practices Indicators Project

• Appropriate environmental conditions in medication preparation and dispensing areas: does the hospital have clean, well-organized, quiet and well-lit medication preparation and dispensing areas?
• Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: does the hospital have guidelines or protocol for nursing practices for controlled ischemia in surgical procedures and post-operative care?
• Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: percentage of failures in monitoring ischemia time and pressure in surgical procedures using pneumatic tourniquet.
• Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: percentage of surgical procedures in which pneumatic tourniquet pressure and time of inflation are recorded.
• Assessment of risk and prevention of malnutrition: does the hospital have guidelines or protocol for prevention of malnutrition?
• Assessment of risk and prevention of malnutrition: percentage of intensive care unit (ICU) patients receiving artificial nutrition whose calorific-protein requirement is calculated on a regular basis.
• Assessment of risk and prevention of malnutrition: percentage of intensive care unit (ICU) patients who are assessed for risk of malnutrition within 24 hours after admission.
• Availability of pharmacist: does the hospital have pharmacists available 24 hours a day?
• Chemotherapy orders: percentage of healthcare professionals who affirm that in their unit or area orders relating to chemotherapy are never given verbally.
• Communication of changes in patient care: percentage of healthcare professionals who affirm that in their unit or area information affecting a patient diagnosis is always communicated clearly and rapidly to all professionals involved in the care of that patient.
• Communication of changes in patient care: percentage of healthcare professionals who affirm that in their unit or area new prescriptions are always ordered revising all the medication being taken by then patient.
• Communication of changes in patient care: percentage of healthcare providers who affirm that in their unit or area changes in patients medications are always communicated clearly and rapidly to all professionals involved in the care of those patients.
• End-of-life care: does the hospital have rules or protocols on terminal patients' preferences and advance directives?
• End-of-life care: percentage of healthcare professionals who affirm that in their unit or area enquiries are always made about terminal patients' preferences regarding life-support procedures and treatment.
• Hand washing: does the hospital have a protocol for hand washing by healthcare providers?
• Hand washing: does the hospital have appropriate infrastructure for hand washing in all units of the hospital in which patient care is administered?
• Hand washing: does the hospital have training courses in hand washing within the last year's training activities?
• Hand washing: percentage of failures in compliance with standard norms on hand washing.
• Identification of high-alert medications: does the hospital have a list of high-alert medications?
• Identification of high-alert medications: does the hospital have norms approved by the hospital on administration on high-alert medications?
• Identification of high-alert medications: does the hospital have norms on labeling and storage of high-alert medications?
• Identification of high-alert medications: does the hospital have pre-printed prescriptions for Cytostatics drugs?
• Influenza vaccination for all hospital workers: percentage of healthcare workers vaccinated against influenza.
• Influenza vaccination for hospital personnel: does the hospital have guidelines or protocol on influenza vaccination for staff?
• Informed consent: percentage of healthcare professionals who affirm that in their unit or area steps are always taken to ensure that patients have understood the risks and complications before they sign the informed consent form.
• Management of anticoagulants: does the hospital have a guideline or protocol for the management of oral anticoagulants by patients, for patients who receive anticoagulants from outpatient clinics or health centers?
• Management of anticoagulants: does the hospital have norms for heparin administration using a nomogram?
• Management of anticoagulants: percentage of patients assessed for weight and renal function before starting anticoagulant therapy with heparin.
• Medication errors: does the hospital have a list, rules or guidelines on abbreviations, symbols and dose designations connected with medication errors?
• Medication errors: does the hospital have a protocol for detection, recording and reporting of medication errors that involves the pharmacy service?
• Medication errors: percentage of medical prescriptions free of non-recommended abbreviations, symbols or dose designations.
• Medication errors: percentage of non-recommended abbreviations, symbols or dose designations used in medical prescription.
• Nurse staff workload: does the hospital assess nursing staff workload?
• Nurse staffing levels: does the hospital have specific rules on nurse staffing levels?
• Preparation of summaries and reports: percentage of healthcare professionals who affirm that in their unit or area clinical reports and summaries are never written without having all the necessary data within sight.
• Prevention of central venous catheter (CVC)-related infections: does the hospital have guidelines or protocol for prevention of CVC-related infections?
• Prevention of central venous catheter (CVC)-related infections: percentage of CVCs in use that are correctly maintained (adequate care).
• Prevention of central venous catheter (CVC)-related infections: percentage of full barrier precautions items not performed when inserting CVCs.
• Prevention of central venous catheter (CVC)-related infections: percentage of maintenance failures in CVCs.
• Prevention of contrast-induced renal damage: does the hospital have guidelines or protocol approved by the hospital for prevention of acute nephropathy caused by exposure to iodine-containing contrast media?
• Prevention of contrast-induced renal damage: percentage of patients at risk of developing acute nephropathy to whom a prevention program is applied prior to tests with iodine-containing contrast media.
• Prevention of contrast-induced renal damage: percentage of patients whose renal function (creatinine level) is assessed within the 24 hours prior to undergoing tests with iodine-containing contrast media.
• Prevention of pressure ulcers: does the hospital have rules for prevention of pressure ulcers?
• Prevention of pressure ulcers: percentage of days at risk of patients over 64 years of age with appropriate postural changes according to their risk of developing pressure ulcers.
• Prevention of pressure ulcers: percentage of patients 65 years of age or older who were assessed within 24 hours of admission to hospital for the risk of developing pressure ulcers.
• Prevention of surgical wound infection: does the hospital have guidelines or protocol approved by the hospital for antibiotic prophylaxis in surgery?
• Prevention of surgical wound infection: does the hospital have guidelines or protocol approved by the hospital for specific nursing practices for post-operative wound care?
• Prevention of surgical wound infection: does the hospital have guidelines or protocol for nursing practices for surgical preparation of skin and mucous?
• Prevention of surgical wound infection: does the hospital take steps to monitor and control normothermia in major surgery (procedures lasting more than two hours).
• Prevention of surgical wound infection: percentage of patients who receive an inspired oxygen fraction greater than or equal to 80% in major surgery (procedures lasting more than two hours) with general anesthesia.
• Prevention of surgical wound infection: percentage of surgical procedures that meet recommendations on antibiotic prophylaxis.
• Prevention of surgical wound infections: percentage of errors (quality defects) in antibiotic prophylaxis for surgical procedures.
• Prevention of venous thromboembolism (VTE): does the hospital have guidelines or protocol for prevention of VTE?
• Prevention of venous thromboembolism (VTE): percentage of patients over 64 years of age assessed in the first 24 hours after admission to hospital for the risk of developing VTE.
• Prevention of wrong-site or wrong-patient surgery: does the hospital have a protocol for prevention of wrong-site or wrong-patient surgery?
• Radiograph labeling: does the hospital have a protocol for prevention of erroneous labeling of radiographs?
• Radiograph labeling: percentage of errors in identification of simple radiographs.
• Radiograph labeling: percentage of simple radiographs that are correctly identified.
• Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocol approved by the hospital on maintenance of cardiac arrest carts?
• Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on correct storage, conservation and restocking of medications in nurse station dispensaries?
• Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on correct storage, conservation, and restocking of medications in pharmacy service?
• Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on labeling and repackaging of medications in unit doses?
• Standardized methods for labeling, packaging and storing medications: does the hospital pharmacy service have a list of antidotes including indication of location, minimum stocks and use-by date control system?
• Standardized methods for labeling, packaging and storing medications: percentage of failures in conservation and storage of medications in the hospital pharmacy.
• Standardized methods for labeling, packaging and storing medications: percentage of failures in labeling of medications prepared in hospital pharmacy service.
• Standardized methods for labeling, packaging and storing medications: percentage of failures in labeling, conservation and storage of medications in wards, emergency department and operating room dispensaries.
• Standardized methods for labeling, packaging and storing medications: percentage of failures in maintenance of medication and equipment available on cardiac arrest carts.
• Unit-dose dispensation: percentage of hospital beds with unit-dose dispensation.
• Validation of medication orders: percentage of prescriptions validated by pharmacy service before dispensation.
• Verbal orders: does the hospital have rules or a protocol on how to deal with verbal orders?
• Verbal orders: percentage of healthcare professionals who affirm that in their unit or area orders received verbally are always written down.
• Verbal orders: percentage of healthcare professionals who affirm that in their unit or area verbal orders are always repeated-back out loud.

Fiscal Year (FY) 2009: Veterans Health Administration (VHA) Performance Measurement System

• 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.
• 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 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.
• Central line associated blood stream infections (CLAB): number of months in which there were no CLAB cases reported for the intensive care unit(s).
• 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.
• Deep vein thrombosis: percentage of patients in high risk diagnostic groups for whom heparin, a heparin agent, or Coumadin is ordered within the first 24 hours of hospitalization.
• 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 risk evaluation completed within 24 hours.
• Depression: percent of patients who during their annual depression screening have a positive score on the PHQ-2 or PHQ-9 or affirmative answer to Question 9 of the PHQ-9 who have timely disposition.
• 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 eligible spinal cord injury & disorders (SCI&D) patients with a diagnosis of diabetes mellitus having a retinal exam by an eye care specialist within specified time periods.
• 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 having full lipid panel in the past year.
• Diabetes mellitus: percent of spinal cord injury & disorders (SCI&D) patients with a diagnosis of diabetes mellitus and blood pressure less than 140/90.
• Diabetes mellitus: percent of spinal cord injury & disorders (SCI&D) patients with a diagnosis of diabetes mellitus having HgbA1c greater than 9 or not done during the measurement 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.
• Hypoglycemia: percentage of intensive care unit patient days in which a glucose level below 45 mg/dl is recorded for those patients on insulin.
• Immunizations: percent of applicable veterans receiving influenza immunization between September 1, 2008 and March 31, 2009 in accordance with defined VHA policy.
• Immunizations: percent of applicable veterans receiving pneumococcal immunization.
• 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, 2008 and March 31, 2009 in accordance with defined VHA policy.
• Influenza immunization: percent of applicable patients age 50 to 64 years receiving influenza immunizations between September 1, 2008 and March 31, 2009 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 remained on an antidepressant drug for at least 84 treatment days (12 weeks) after the Index Prescription Date.
• Obesity: percentage of eligible veterans screened for obesity within the past year.
• Palliative care: percentage of veterans who died as an inpatient in a VA owned or operated facility who had a palliative care consult within the 12 months prior to death.
• Pneumococcal immunization: percent of applicable patients receiving pneumococcal immunization.
• Post traumatic stress disorder (PTSD): percent of patients screened positive for PTSD symptoms with PC-PTSD who have documentation of a disposition completed within 24 hours of a positive PC-PTSD screen.
• Post-traumatic stress disorder (PTSD): percent of eligible patients screened at required intervals for PTSD and, if positive PC-PTSD result, who have suicide risk 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.
• Tobacco: percent of veterans using tobacco who have been offered a referral to smoking cessation specialty program to assist with cessation within the past year.
• Tobacco: percent of veterans using tobacco who have been offered medications to assist with cessation.
• Tobacco: percent of veterans using tobacco who have been provided with brief counseling within the past year.
• Ventilator associated pneumonia (VAP): number of months in which there were no VAP cases reported for the intensive care unit(s).