Agency for Healthcare Research and Quality (AHRQ) Quality Indicators

• Accidental puncture or laceration: rate per 1,000 eligible discharges.

Ambulatory Surgery Center (ASC) Quality Measures

• Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions experiencing a burn prior to discharge.
• Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions experiencing a fall within the confines of the ASC.
• Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.
• Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions who experienced a wrong site, side, patient procedure or implant.
• Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who receive the prophylactic antibiotic on time.

Australian Council on Healthcare Standards (ACHS) Equip Clinical Indicators

• Anatomical pathology: percentage of validated large biopsy results with a turnaround time (Collected to Validated time) less than 96 hours, during the 1-2 week time period.
• Anatomical pathology: percentage of validated large biopsy results with a turnaround time (Received to Validated time) less than 92 hours, during the 1-2 week time period.
• Anatomical pathology: percentage of validated small biopsy results with a turnaround time (Collected to Validated time) less than 48 hours, during the 1-2 week time period.
• Anatomical pathology: percentage of validated small biopsy results with a turnaround time (Received to Validated time) less than 44 hours, during the 1-2 week time period.
• Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period, excluding same day admissions.
• Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period.
• Average length of stay: percentage of inpatients in an acute unit with a length of stay greater than 30 days, during the 6 month time period.
• Blood transfusion: percentage of adverse transfusion events related to a blood transfusion episode, during the 6 month time period.
• Blood transfusion: percentage of red blood cell (RBC) transfusion episodes when the HB reading is 100g/L or more, during the 6 month period.
• Blood transfusion: percentage of transfusion episodes where informed patient consent was not documented, during the 6 month time period.
• Cardiology: percentage of inpatients undergoing coronary artery bypass grafts within 24 hours of percutaneous transluminal coronary angioplasy (PCTA) (with or without stenting) in the same admission, during the 6 month time period.
• Cardiology: percentage of patients with acute myocardial infarction (AMI) requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the hospital, during the 6 month time period.
• Cardiology: percentage of vessels in which percutaneous transluminal coronary angioplasy (PTCA) (with or without stenting) is undertaken where primary success, as defined, is achieved, during the 6 month time period.
• Cardiothoracic surgery: percentage of elective patients who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.
• Cardiothoracic surgery: percentage of patients aged 71 years or greater who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.
• Cardiothoracic surgery: percentage of patients who die in the same admission as having coronary artery graft surgery, during the 6 month time period.
• Cataract surgery: percentage of patients having a discharge intention of 1 day who had an overnight admission following cataract surgery, during the 6 month time period.
• Cataract surgery: percentage of patients having an anterior viterctomy at the time of cataract surgery, during the 6 month time period.
• Cataract surgery: percentage of patients having readmissions within 28 days of the discharge following cataract surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
• Cataract surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following cataract surgery, during the 6 month time period.
• Chemical pathology: percentage of serum/plasma potassium validated report results for ED (or requests specified as urgent) with a turnaround time (received to validated time) less than 60 minutes during the 2-4 week time period.
• Children's dental care: percentage of deciduous teeth requiring extraction within 6 months following pulpotomy treatment, during the time period under study.
• Children's dental care: percentage of teeth requiring re-treatment (restoration, endodontic or extraction) within 24 months of the initial fissure sealant treatment.
• Children's dental care: percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment.
• Colonoscopy: percentage of patients treated for possible perforation NOT related to polypectomy, during 6 month time period.
• Colonoscopy: percentage of patients who have bleeding, during 6 month time period.
• Consultation process: percentage of patients waiting more than 14 days from the date ready for care, to the date of commencing radiotherapy, during 1 week in May or November period.
• Consultation process: percentage of patients who have informed consent recorded in the medical record before receiving radiotherapy, during 1 week in May or November period.
• Continuity of care: percentage of inpatients who have a discharge summary or letter, at the time of discharge, during the 6 month time period.
• Continuity of care: percentage of inpatients who have a final discharge summary recorded in the medical record within 2 weeks of hospital discharge, during the 6 month time period.
• Day of surgery admissions: percentage of elective surgery patients admitted to the organization on the day of surgery, during the 6 month time period.
• Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have an unplanned extension to the time between entry into the post-anaesthesia care unit to the meeting of hospital/day surgery discharge criteria, during the time period under study.
• Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have received a pre-anaesthesia assessment before the day of day surgery, during the time period under study.
• Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients whose procedure is cancelled on the day of surgery for anaesthetic reasons other than an acute medical condition, during the time period under study.
• Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients with unplanned overnight admissions for anaesthetic reasons, during the time period under study.
• Delayed patient discharge: percentage of patients who have an operation/procedure performed in the day procedure facility who have an unplanned delayed discharge greater than 1 hour beyond the expected for the procedure, during the 6 month time period.
• Dermatological consult: percentage of patients who receive a dermatological consult longer than one week after the primary contact time to assessment visit, during the 6 month time period.
• Dermatological consult: percentage of patients who receive a dermatological consult within 24 hours of the primary contact time to assessment visit, during the 6 month time period.
• Dermatological consult: percentage of patients who receive a dermatological consult within greater or equal to 1 day and less than 2 days of the primary contact time to assessment visit, during the 6 month time period.
• Dermatological consult: percentage of patients who receive a dermatological consult within greater or equal to 2 days and less than 5 working days of the primary contact time to assessment visit, during the 6 month time period.
• Diagnosis and care planning: percentage of inpatients with an individual care plan which is constructed and regularly reviewed with the consumer, during the 6 month time period.
• Diagnosis and care planning: percentage of patients allocated a diagnosis within 24 hours of admission, during the 6 month time period.
• Diagnosis and care planning: percentage of patients with a diagnosis on hospital discharge, which is recorded in the medical record, during the 6 month time period.
• Discharge destination: percentage of patients who have completed a rehabilitation program and been discharged to their pre-episode form of accommodation, or a form of accommodation that allows great independence, during the 6 month period.
• Discharge plan: percentage of separations for which there is an appropriate discharge plan for a patient, during the 6 month period.
• Electro convulsive therapy: percentage of inpatients experiencing major medical complications while undergoing electro convulsive therapy (ECT), during the 6 month time period.
• Electro convulsive therapy: percentage of inpatients undergoing more than 12 treatments of electro convulsive therapy (ECT), during the 6 month time period.
• Endocrinology: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, whose medical record shows at least 4 blood glucose measurements on the first post-operative day, during the 6 month time period.
• Endocrinology: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, with a recorded blood glucose level less than 4 mmol/L in the post-operative period, during the 6 month time period.
• Endodontic treatment: percentage of teeth extracted within 12 months of completing a course of endodontic treatment, during the time period under study.
• Endodontic treatment: percentage of teeth retreated between 1 and 6 months of completing a course of endodontic treatment, during the time period under study.
• Functional assessment: percentage of inpatients for whom there is documented evidence of a functional assessment within 72 hours prior to cessation of an inpatient rehabilitation program, during the 6 month time period.
• Functional assessment: percentage of patients admitted to a rehabilitation unit/facility for whom there is documented evidence of a functional assessment within 72 hours of patient admission, during the 6 month period.
• Functional gain: percentage of patients who have completed a rehabilitation program and for whom there is documented evidence of functional gain, during the 6 month period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion and endoscopic therapy, who subsequently have an operation, during the 6 month time period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion and have a gastroscopy within 24 hours of admission, during the 6 month time period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion and subsequently die, during the 6 month time period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion, and have an operation, during the same admission, during the 6 month time period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion, for which there is documented evidence that a member of the surgical staff has been notified of their condition, during the 6 month time period.
• Gastroenterology: percentage of patients admitted to hospital with haematemesis and/or malaena, who receive a blood transfusion, who are discharge with a specific diagnosis that explains the cause of bleeding, during the 6 month time period.
• General surgery: percentage of patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention, during the 6 month time period.
• Geriatric medicine: percentage of patients admitted to geriatric medicine or geriatric rehabilitation unit for whom there is documented assessment of mental function on admission or during admission when more appropriate, during the 6 month time period.
• Geriatric medicine: percentage of patients admitted to geriatric medicine or geriatric rehabilitation unit for whom there is documented assessment of physical function on admission and at least once more during the inpatient stay, during the 6 month time period.
• Glaucoma surgery: percentage of patients having a readmission within 28 days of discharge following glaucoma surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
• Glaucoma surgery: percentage of patients with a LOS greater than 3 days following glaucoma surgery, during the 6 month time period.
• Glaucoma surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following glaucoma surgery, during the 6 month time period.
• Haematology: percentage of Coag validated report results from ED with a turnaround time (Collected to Validated time) less than 60 minutes during the 2-4 week time period.
• Haematology: percentage of Coag validated report results from ED with a turnaround time (Received to Validated time) less than 40 minutes during the 2-4 week time period.
• Haematology: percentage of haemoglobin validated report results from ED with a turnaround time (Collected to Validated time) less than 60 minutes during the 2-4 week period.
• Haemotology: percentage of haemoglobin validated report results from ED with a turnaround time (Received to Validated time) less than 40 minutes during the 2-4 week time period.
• Hospital in the home: percentage of patients having 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.
• Hospital in the home: percentage of patients having an unplanned return to hospital where the patient does not return to the Hospital in the Home program, during that admission, during the 6 month time period.
• Hospital in the home: percentage of patients having more than 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.
• Hospital in the home: percentage of patients making 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.
• Hospital in the home: percentage of patients making more than 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.
• Hospital in the home: percentage of patients who have an unplanned return to the hospital and are transferred back to the Hospital in the Home program after 24 hours, during the 6 month time period.
• Hospital in the home: percentage of patients who have an unplanned return to the hospital and are transferred back to the Hospital in the Home program within 24 hours, during the 6 month time period.
• Hospital in the home: percentage of patients who have an unplanned return to the hospital, during the 6 month time period.
• Hospital re-admission: percentage of unplanned and unexpected re-admissions within 14 days of seperation, during the 6 month time period.
• Hospital re-admission: percentage of unplanned and unexpected re-admissions within 28 days of seperation, during the 6 month time period.
• Infection surveillance: percentage AV-fistula access-associated blood stream infections, during the 6 month time period.
• Infection surveillance: percentage babies of birth weight less than 1000g 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.
• Infection surveillance: percentage babies of greater than or equal to 1000g 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.
• Infection surveillance: percentage centrally inserted cuffed line access-associated blood stream infections, during the 6 month time period.
• Infection surveillance: percentage centrally inserted non-cuffed line access-associated blood stream infections, during the 6 month time period.
• Infection surveillance: percentage live babies born at the reporting hospital who develop blood stream and/or cerebral spinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.
• Infection surveillance: percentage live babies of >37 weeks estimated gestational age (GA) born at the reporting hospital who develop blood stream and/or cerebral spinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.
• Infection surveillance: percentage native vessel graft access-associated blood stream infections, during the 6 month time period.
• Infection surveillance: percentage of adult intensive care units (ICU)-associated centrally-inserted central line associated blood stream infection (CI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of adult intensive care units (ICU)-associated peripherally-inserted central associated blood stream infection (PI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of deep incisional surgical site infections (SSI) in hip prosthesis procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep incisional surgical site infections (SSI) in knee prosthesis procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep incisional/organ space surgical site infections (SSI) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed)performed, during the 6 month time period.
• Infection surveillance: percentage of deep incisional/organ space surgical site infections (SSI)(in chest incision site) in coronary artery bypass graft procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep incisional/organ space surgical site infections (SSI)(in the donor incision site) in coronary artery bypass graft procedures performed (involving chest and donor incisions), during the 6 month time period.
• Infection surveillance: percentage of deep/incisional/organ space surgical site infections (SSI) in abdominal hysterectomy procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep/incisional/organ space surgical site infections (SSI) in lower segment caesarean section procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep/incisional/organ space surgical site infections (SSI) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.
• Infection surveillance: percentage of deep/incisional/organ space surgical site infections (SSI) infemoral-popliteal bypass procedures performed, during the 6 month time period.
• Infection surveillance: percentage of haematology unit-related centrally-inserted central line associated blood stream infection (CI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of haematology unit-related peripherally-inserted central line associated blood stream infection (PI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of intensive care unit (ICU) associated new methicillin resistant staphylococcus aureus (MRSA) healthcare associated infections in non-sterile site, during the 6 month time period.
• Infection surveillance: percentage of intensive care unit (ICU) associated new methicillin resistant staphylococcus aureus (MRSA) healthcare associated infections in sterile site, during the 6 month time period.
• Infection surveillance: percentage of non-intensive care unit (ICU) associated new methicillin resistant staphylococcus aureus (MRSA) healthcare associated infections in non-sterile site, during the 6 month time period.
• Infection surveillance: percentage of non-intensive care unit (ICU) associated new methicillin resistant staphylococcus aureus (MRSA) healthcare associated infections in sterile site, during the 6 month time period.
• Infection surveillance: percentage of oncology unit-related centrally-inserted central line associated blood stream infection (CI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of oncology unit-related peripherally-inserted central line associated blood stream infection (PI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of outpatient intravenous therapy (OPIV) unit-related centrally-inserted central line associated blood stream infection (CI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of outpatient intravenous therapy (OPIV) unit-related perpherally-inserted central line associated blood stream infection (PI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of paediatric intensive care unit (ICU)-associated centrally-inserted central line associated blood stream infection (CI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of paediatric intensive care unit (ICU)-associated peripherally-inserted central line associated blood stream infection (PI-CLAB), during the 6 month time period.
• Infection surveillance: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of greater than or equal to 1000g birth weight, occurring more than 48 hours of birth, during the 6 month time period.
• Infection surveillance: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of less than 1000g birth weight occurring more than 48 hours of birth during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI) in hip prosthesis procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI) in knee prosthesis procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI) in lower segment caesarean section procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI)(in chest incision site) in coronary artery bypass graft procedures performed, during the 6 month time period.
• Infection surveillance: percentage of superficial incisional surgical site infections (SSI)(in the donor incision site) in coronary artery bypass graft procedures performed (involving chest and donor incisions), during the 6 month time period.
• Infection surveillance: percentage of superficial surgical site infections (SSI) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed)performed, during the 6 month time period.
• Infection surveillance: percentage of superficial surgical site infections (SSI) infemoral-popliteal bypass procedures performed, during the 6 month time period.
• Infection surveillance: percentage synthetic graft access-associated blood stream infections, during the 6 month time period.
• Intra-operative period: percentage of patients receiving a blood transfusion in accordance with National Health and Medical Research Council (NH & MRC) guidelines during a surgical procedure with an anaesthetist in attendance, during the time period under study.
• Intra-operative period: percentage of patients undergoing a procedure with an anaesthetist in attendance, who have documented evidence of intra-operative cardiac dysrhythmia/arrest, during the time period under study.
• Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where the anaesthesia records substantially complies with the Australian and New Zealand College of Anaesthetists (ANZCA) requirements for the anaesthetic record, during the time period under study.
• Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where there is an assistant to an anaesthetist, during the time period under study.
• Long term care: percentage of inpatients who have a multidisciplinary review recorded every 3 months, during the 6 month time period.
• Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have read acute pain protocols, during the time period under study.
• Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have received education regarding acute pain management, during the time period under study.
• Management of acute pain: percentage of patients having neuraxial, or plexus block analgesic technique, demonstrating neurological dysfunction three months post-procedure secondary to neuraxial technique or plexus block.
• Management of acute pain: percentage of patients receiving acute pain management developing severe hypotension, requiring an alteration to or change of analgesic technique, during acute pain management, during the time period under study.
• Management of acute pain: percentage of patients receiving acute pain management developing severe respiratory depression requiring naloxone administration during acute pain management, during the time period under study.
• Management of acute pain: percentage of patients receiving acute pain management who are satisfied with their current pain relief, during the time period under study.
• Management of acute pain: percentage of patients receiving acute pain management with analgesia adequate to allow acute rehabilitation (e.g., effective cough, mobilisation), during the time period under study.
• Management of acute pain: percentage of patients receiving acute pain management with pain intensity scores regularly recorded by nursing staff, during the time period under study.
• Management of acute pain: percentage of patients receiving neuraxial blockade as part of their acute pain management who develop an epidural abscess or epidural haematoma following neuraxial blockade, during the time period under study.
• Management of acute pain: percentage of patients reporting nausea and vomiting whilst receiving prescribed antiemetic treatment when nausea and vomiting are present, during acute pain management, during the time period under study.
• Mental health inpatient: percentage of voluntary inpatient admissions, during the 6 month time period.
• Microbiology: percentage of validated CSF results from ED with a microscopy (+/- gram stain) with a turnaround time (Received to Validated time) less than 40 minutes, during the 1-2 month time period.
• Microbiology: percentage of validated CSF results from ED for microscopy (+/- gram stain) with a turnaround time (Collected to Validated time) less than 60 minutes, during the 1-2 month time period.
• Morbidity of radiological procedures: percentage of patients experiencing iodinated contrast extravasation requiring medical review during an IV contrast enhanced CT procedure, during the 6 month period.
• Morbidity of radiological procedures: percentage of patients undergoing percutaneous transpleural biopsy of the lung or mediastinum, for whom there is documented evidence of pneumothorax and/or haemothorax requiring intervention following the procedure, during the 6 month period.
• Morbidity of radiological procedures: percentage of peripheral embolic complications during angioplasty of the arteries in upper or lower limbs, during the 6 month period.
• Morbidity of radiological procedures: percentage of puncture site complications during or following angiography, during the 6 month period.
• Nephrology: percentage of inpatients having a renal biopsy who subsequently develop macroscopic haematuria in any of their voided urine specimens with 24 hours of the procedure, during the 6 month time period.
• Neurology: percentage of inpatients separated from hospital with a discharge diagnosis of stoke that had a documented CT scan, during the 6 month time period.
• Neurosurgery: percentage of patients having a neurosurgical infection in hospital, excluding superficial wound infections, requiring nothing more than a single short course of antibiotics, during the 6 month time period.
• Neurosurgery: percentage of patients with a new neurological deficit following a neurosurgery procedure, during the 6 month time period.
• Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures in the labour ward for whom there is documented evidence of informed consent for labour ward epidural/spinal analgesia, during the time period under study.
• Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures who experience a post-dural puncture headache, during the time period under study.
• Obstetric anaesthesia care: percentage of patients requiring immediate lower segment Caesarean section (LSCS) who deliver within 30 minutes of request for immediate LSCS, during the time period under study.
• Obstetric anaesthesia care: percentage of patients undergoing lower segment Caesarean section (LSCS) who receive a general anaesthetic for LSCS, during the time period under study.
• Obstetrics: percentage of deliveries with birth weight less than 2750g at 40 weeks gestation or beyond.
• Obstetrics: percentage of high risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis.
• Obstetrics: percentage of selected primapara sustaining a perineal tear and NO episiotomy.
• Obstetrics: percentage of selected primapara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally.
• Obstetrics: percentage of selected primipara undergoing episiotomy and NO perineal tear while giving birth vaginally.
• Obstetrics: percentage of selected primipara who have a spontaneous vaginal birth.
• Obstetrics: percentage of selected primipara who undergo induction of labour.
• Obstetrics: percentage of selected primipara who undergo instrumental vaginal birth.
• Obstetrics: percentage of selected primipara undergoing caesarean section.
• Obstetrics: percentage of serious adverse events that are addressed within a peer review process.
• Obstetrics: percentage of term babies born with an Apgar score of less than 7 at five minutes post delivery.
• Obstetrics: percentage of women having a general anaesthetic for caesarean section.
• Obstetrics: percentage of women who gave birth vaginally who require a blood transfusion during the same admission.
• Obstetrics: percentage of women who receive an appropriate prophylactic antibiotic at the time of caesarean section.
• Obstetrics: percentage of women who undergo a caesarean section who require a blood transfusion during the same admission.
• Oncology: percentage of pre-menopausal patients with stage II carcinoma of the breast for whom there is documented evidence of treatment, or intention to treat, with polychemotherapy, during the 6 month time period.
• Orthopaedic surgery: percentage of patients undergoing primary total hip joint replacement (THJR) having a postoperative in hospital infection, during the 6 month time period.
• Otolaryngology: percentage of patients who have a significant reactionary haemorrhage following tonsillectomy, during the 6 month time period.
• Outcome process: percentage of patients who had radiotherapy for breast conserving (pT1-3 any nodal staging, M0), during the 6 month time period, who had complete follow-up.
• Outcome process: percentage of patients who had radiotherapy for glottis cancer (T1-2 N0 M0), during the 6 month time period, who had complete follow-up.
• Paediatric immunisation: percentage of infants admitted as inpatients for whom there is documented current immunisation status, during the 6 month time period.
• Paediatric immunisation: percentage of infants admitted as inpatients with not up to date immunisation status for whom there is documented evidence that they were either given catch up immunisations; or that such immunisation was planned, during the 6 month time period.
• Paediatric intensive care unit (ICU) access: percentage of appropriate patients referred to an ICU, who are not admitted to the unit because of inadequate resources, during the 6 month time period.
• Paediatric intensive care unit (ICU) access: percentage of elective surgical cases deferred or cancelled due to lack of ICU/HDU bed, during the 6 month time period.
• Paediatric intensive care unit (ICU) access: percentage of patients who were transferred to another facility/area/ICU due to unavailability of an ICU bed, during the 6 month time period.
• Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, but significant other intra-abdominal pathology, during the 6 month time period.
• Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, during the 6 month time period.
• Paediatric surgery: percentage of patients having a pyloromyotomy in which mucosal perforation occurs and is detected at the time of the operation or later, during the 6 month time period.
• Patient record audits: percentage of patients with completed and updated medical history, during the time period under study.
• Patient record audits: percentage of patients with completed charting at initial assessment for general course of care, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who are reviewed by an anaesthetist to manage severe pain, not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for a temperature recorded in the recovery period of less than 35 degrees Celsius, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for cardiovascular reasons, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for post-operative nausea and vomiting not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for respiratory or cardiac arrest, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to relieve respiratory distress, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to treat inadequate reversal of neuro-muscular blockade, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure who undergo review by an anaesthetist for other reasons, in the recovery period, during the time period under study.
• Patient recovery period: percentage of patients undergoing a procedure with an anaesthetist in attendance, who have an unplanned post-anaesthesia care unit (PACU) stay longer than two hours, during the time period under study.
• Phototherapy: percentage of patients receiving broad band UVB phototherapy, during the 6 month time period.
• Phototherapy: percentage of patients receiving narrow band UVB phototherapy, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy for eczema, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy for other dermatoses, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy for Psoriasis, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where a protocol for dose and documentation of side effects were used, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the explanation of phototherapy and side effects, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the total UVB dose administered, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of treatment outcome at the conclusion of the phototherapy course, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of written informed consent, during the 6 month time period.
• Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence that contraindications were considered, during the 6 month time period.
• Physical examination of patients: percentage of inpatients with a complete documented physical examination within 48 hours of admission, during the 6 month time period.
• Plastic surgery: percentage of completely excised malignant skin tumors, during the 6 month time period.
• Post-operative period: percentage of patients receiving anaesthesia care having an unplanned admission to an intensive care or high dependency unit within 24 hours of a procedure with an anesthetist in attendance, during the time period under study.
• Post-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, for which there is documented evidence of a post anaesthesia review, or other process as determined by the anaesthetic department, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care in whom it is judged that there has been adequate peri-operative management of current medications (e.g., diabetic medication), during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have consent for the administration of anaesthesia or sedation documented in the patient chart, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received information about the risks associated with the anaesthesia technique, as documented in the patient chart, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written information on the anaesthesia technique, as documented in the patient chart, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written, verbal, or visual information on the anaesthesia technique, as documented in the patient chart, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care who, according to the relevant protocol, qualify for preoperative ECG recording who have undergone an ECG tracing according to the departmental or established protocols, during the time period under study.
• Pre-anaesthesia period: percentage of patients receiving anaesthesia care with a history of post operative nausea and vomiting (PONV) to whom a prophylactic anti-emetic has been administered, during the time period under study.
• Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by an anaesthetist, during the time period under study.
• Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by the anaesthetist who will be responsible for their anaesthesia care, during the time period under study.
• Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who are seen by an anaesthetist before entering the operating theatre suite, anaesthetic room, or procedure room, during the time period under study.
• Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who receive an anaesthesia assessment by an anaesthetist, of an appropriate duration, during the time period under study.
• Prescribing patterns: percentage of inpatients on 3 or more psychotropic medication from 1 subgroup category specified, at the time of discharge, during the 6 month time period.
• Pressure ulcers: percentage of inpatients who develop one or more pressure ulcers, during their admission, during the 6 month time period.
• Refractive surgery: percentage of patients having a discharge intention of 1 day, who had an overnight admission following refractive surgery, during the 6 month time period.
• Refractive surgery: percentage of patients having an anterior virectomy at the time of refractive surgery, during the 6 month time period.
• Refractive surgery: percentage of patients with a complication (medical or surgical) within 28 days following excimer laser surgery, during the 6 month time period.
• Refractive surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following refractive surgery, during the 6 month time period.
• Refractive surgery: percentage of unplanned readmissions within 28 days of discharge, following refractive surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
• Rehabilitation plan: percentage of patients admitted to a rehabilitation unit/facility for whom there is documented established multidisciplinary rehabilitation plan within 7 days of patient admission, during the 6 month period.
• Report availability: percentage of reports on radiographic examinations not available to the referring doctor within 24 hours of completion, during that 7 day time period.
• Retinal detachment surgery: percentage of patients having an unplanned reoperation the same eye within 28 days, following retinal detachment surgery, during the 6 month time period.
• Retinal detachment surgery: percentage of patients with a LOS greater than 4 days, following retinal detachment surgery, during the 6 month time period.
• Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
• Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, during the 6 month time period.
• Return to the operating room: percentage of patients having an operation or procedure in an operating room who had an unplanned return to the operating room during the same admission, during the 6 month time period.
• Skin tumor pathology (biopsy book): percentage of histopathology specimens taken with a skin tumor histopathological diagnosis, during the 6 month time period.
• Skin tumor pathology (biopsy book): percentage of histopathology specimens taken with a skin tumor working diagnosis, during the 6 month time period.
• Surgical repair of lower genital tract: percentage of primiparous patients requiring surgical repair of the lower genital tract for fourth degree tear, defined above, during the 6 month time period.
• Surgical repair of lower genital tract: percentage of primiparous patients requiring surgical repair of the lower genital tract for third degree tear, defined above, during the 6 month time period.
• Surgical repair of lower genital tract: percentage of primiparous patients with an inner lower genital tract defined above, during the 6 month time period.
• Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented evidence of an appropriate discharge plan, during the 6 month time period.
• Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity in addition to the initial assessment, which facilitates ongoing inpatient management, during the 6 month time period.
• Thoracic medicine: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity on initial presentation, during the 6 month time period.
• Thromboprophylaxis: percentage of high-risk medical patients admitted who receive venous thromboembolism (VTE) prophylaxis, during the 6 month time period.
• Treatment process: percentage of curative megavoltage radiotherapy courses provided, where CT planning was utilized, during the 6 month period.
• Treatment process: percentage of patients receiving megavoltage radiotherapy using multi-leaf collimators (MLC), during the 6 month period.
• Treatment process: percentage of patients receiving radiotherapy, who have a letter on file to the referring doctor and general practitioner, regarding the current radiotherapy course, during 1 week in May or November.
• Treatment process: percentage of patients who receive curative chemotherapy for squamous cell carcinoma (SCC) of the cervix in the definitive or the postoperative setting, during the 6 month period.
• Treatment process: percentage of patients with squamous cell carcinoma (SCC) of the oral cavity, otopharynx and larynx who wait longer than 6 weeks from their definitive surgery to commencing their radiotherapy, during the 6 month period.
• Unplanned return to operating room: percentage of patients who have an operation/procedure performed in the day procedure facility who have an unplanned return to the operating/procedure room, during the 6 month period.
• Unplanned returns to the dental centre: percentage of attendances for complications within 7 days of routine extraction, during the time period under study.
• Unplanned returns to the dental centre: percentage of attendances for complications within 7 days of surgical extraction, during the time period under study.
• Unplanned returns to the dental centre: percentage of teeth requiring retreatment within 6 months of an episode of restorative treatment, during the time period under study.
• Unplanned transfer: percentage of patients who have an operation/procedure performed in the day procedure facility with a discharge intention of one day, who had an unplanned transfer following an operation/procedure, during the 6 month time period.
• Urology: average number of patient days (from the first day after surgery) for all patients having a Transurethral Resection (TUR) for benign prostatomegaly (excluding patients having other procedures), during the 6 month time period.
• Urology: average operating time (minutes) for all patients undergoing a Transurethral Resection (TUR) for benign prostatomegaly, during the 6 month time period.
• Urology: percentage of patients having a Transurethral Resection (TUR) for benign prostatomegaly, who have a blood transfusion (intra-operatively or post-operatively) within the same admission, during the 6 month time period.
• Urology: percentage of patients having an unplanned readmission within 28 days of discharge following Transurethral Resection (TUR) for benign prostatomegaly, during the 6 month time period.
• Use of seclusion: percentage of inpatients experiencing major medical complications while in seclusion, during the 6 month time period.
• Use of seclusion: percentage of inpatients having at least 1 episode of seclusion, in an admission, during the 6 month time period.
• Use of seclusion: percentage of inpatients having at least one episode of physical restraint, in an admission, during the 6 month time period.
• Use of seclusion: percentage of inpatients having seclusion, during the 6 month time period.
• Use of seclusion: percentage of inpatients in seclusion who were not reviewed by sight, by a medical practitioner or nurse on at least a half-hourly basis, during the 6 month time period.
• Vaginal delivery following caesarean: percentage of patients delivering vaginally following a previous primary caesarean section, as defined above, during the 6 month time period.
• Vascular surgery: percentage of patients having a cartoid endocarterectomy who have a stroke within the same admission, during the 6 month time period.
• Vascular surgery: percentage of patients having an elective abdominal aortic aneurysm (AAA) repair, who die within the same admission, during the 6 month time period.

National Hospital Quality Measures

• Acute myocardial infarction (AMI): 30-day mortality rate.
• Heart failure (HF): 30-day mortality rate.
• Pneumonia: 30-day mortality rate.

HealthPartners Clinical Indicators

• Cardiovascular disease (CVD): percentage of members with a diagnosis of CVD who have optimally managed modifiable cardiovascular risk factors (LDL cholesterol, blood pressure, daily aspirin use, non-tobacco use).
• Cervical cancer screening: percentage of women ages 21 and older in the measurement year screened in accordance with evidence-based standards.
• Depression: percentage of members diagnosed with a new episode of depression, treated with antidepressant medication and optimally managed.
• Preventive services: percentage of adult enrolled members that are up-to-date for all appropriate preventive services.
• Preventive services: percentage of enrolled child and adolescent members who are up-to-date for all appropriate preventive services.

Diagnosis and Outpatient Management of Asthma Measures

• Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication.
• Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication.
• Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record.
• Diagnosis and management of asthma: percentage of patients with asthma with spirometry or peak flow meter reading documented in the medical record at the last visit.

Diagnosis and Treatment of Respiratory Illness in Children and Adults Measures

• Diagnosis and treatment of respiratory illness in children and adults: percentage of encounters for cold symptoms (phone care and/or office visits) for which there is documentation of home treatment education.
• Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis that had strep screen testing.
• Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than 7 days and who receive an antibiotic.

Disease-specific Care Certification Program

• Stroke: percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
• Stroke: percent of ischemic stroke patients with LDL greater than 100, or LDL not measured, or on cholesterol-reducer prior to admission, who are discharged on cholesterol reducing drugs.
• Stroke: percent of non-ambulatory ischemic or hemorrhagic stroke patients who have had DVT prophylaxis initiated by the end of hospital day two.
• Stroke: percent of 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 patients with an ischemic stroke with atrial fibrillation discharged on anticoagulation therapy.
• Stroke: percent of patients with ischemic or hemorrhage stroke or their caregivers who were given education or educational materials during their hospital stay addressing all five specified education categories.
• Stroke: percent of patients with ischemic or hemorrhage stroke with a history of smoking cigarettes, who are, or whose caregivers are, given smoking cessation advice or counseling during their hospital stay.
• Stroke: percent of patients with ischemic stroke or hemorrhage stroke who undergo screening for dysphagia with a simple valid bedside testing protocol before being given any food, fluids, or medications by mouth.
• Stroke: percent of patients with ischemic stroke or hemorrhage stroke who were assessed for rehabilitation services.
• Stroke: percent of patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two.

HEDIS® 2008: Healthcare Effectiveness Data and Information Set

• Acute myocardial infarction (AMI): percentage of adult members 18 years of age and older with a diagnosis of AMI who received persistent beta-blocker treatment for six months after being discharged alive from the hospital.
• Adults' access to preventive/ambulatory health services: percentage of enrollees who had an ambulatory or preventive-care visit.
• 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.
• Antidepressant medication management (effective acute treatment phase): percentage of members who were diagnosed with a new episode of major depression and treated with antidepressant medication, who remained on an antidepressant drug during the entire 84-day (12-week) acute treatment phase
• Antidepressant medication management (effective continuation phase treatment): percentage of members who were diagnosed with a new episode of major depression and treated with antidepressant medication, who remained on an antidepressant drug for at least 180 days.
• Antidepressant medication management (optimal practitioner contacts for medication management): percentage of members who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who had at least three follow-up contacts with a practitioner coded with a mental health diagnosis during the 84-day (12-week) acute treatment phase.
• Attention-deficit/hyperactivity disorder (ADHD) (continuation maintenance phase): percentage of members 6 to 12 years of age with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 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.
• Children and adolescents' access to primary care practitioners: percentage of enrollees who had a visit with a managed care organization (MCO) primary care practitioner.
• 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.
• 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% (good control).
• 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 enrolled 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) dependence treatment: percentage of adolescents and adults diagnosed with AOD dependence disorders who receive two additional AOD services within 30 days after the initiation of AOD treatment.
• 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 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 much of a problem they had in getting needed care for their child.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with health plan customer service for their child.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often the staff at their child's doctor's office or clinic treated them and their child with courtesy and respect, and were helpful.
• 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 or other health providers communicated well.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their health plan handled their child's claims correctly and in a reasonable time.
• 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 shared decision making 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 or nurse for their children with chronic conditions.
• Health plan members' experiences: percentage of parents or guardians of health plan members who reported they received assistance with coordination of care and services for their children with chronic conditions.
• 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 or equal to 140/90 mm Hg) during the measurement year.
• 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.
• Influenza immunization: percentage of members 50 to 64 years of age who received an influenza vaccination between September 1 of the measurement year and the date on which the CAHPS® 4.0H Adult Survey was completed.
• Initiation of alcohol and other drug (AOD) dependence treatment: percentage of adolescents and adults diagnosed with AOD dependence who initiate treatment through either an inpatient AOD admission or an outpatient service for AOD dependence and an additional AOD service within 14 days.
• 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.
• 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 days 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 and who discussed or were recommended smoking cessation methods or strategies.
• Smoking cessation: percentage of members 18 years of age and older who were current smokers, who were seen by a health plan practitioner during the measurement year and who discussed or were recommended smoking cessation medications.
• Smoking cessation: percentage of members 18 years of age and older who were current smokers, who were seen by a health plan practitioner during the measurement year and who received advice to quit smoking.
• Timeliness of prenatal care: percentage of deliveries that received a prenatal care visit as a member of the managed care organization (MCO) in the first trimester or within 42 days of enrollment in the MCO.
• 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.

The Physician Consortium for Performance Improvement® Measurement Sets

• Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care.
• Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period.
• Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile.
• Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February).
• Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period.
• Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care.
• End stage renal disease (ESRD): percentage of calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis have a Hgb greater than or equal to 11 AND patients have a Hgb less than 11 with a documented plan of care.
• End stage renal disease (ESRD): percentage of calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis have a Kt/V greater than or equal to 1.2 AND patients have a Kt/V less than 1.2 with a documented plan of care.
• End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the 12 month reporting period.
• End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula AND patients who are referred for an AV fistula/permanent vascular access at least once during the 12 month reporting period.
• End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 AND patients have a Kt/V less than 1.7 with a documented plan of care at least twice during the 12 month reporting period.
• End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD with a permanent catheter after 90 days on dialysis who are referred for evaluation for permanent vascular access at least once during the 12 month reporting period.
• Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.
• Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.
• Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.
• Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
• Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.
• Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formation for preventing progression of AMD.
• Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
• Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.
• Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.
• Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
• Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented.
• Geriatrics: percentage of patients aged 65 years and older who were screened for fall risk (2 or more falls in the past year or any fall with injury in the past year) at least once within 12 months.
• Geriatrics: percentage of patients aged 65 years and older with documentation of a surrogate decision maker or advance care plan in the medical record.
• Hepatitis C: percentage of female patients aged 18 to 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment who were counseled regarding contraception prior to the initiation of treatment.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom HCV genotype testing was performed prior to initiation of treatment.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom quantitative HCV RNA testing was performed at 12 weeks of treatment.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of treatment.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were considered for peginterferon and ribavirin therapy within the 12 month reporting period.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed peginterferon and ribavirin therapy within the 12 month reporting period.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C with genotype 1 or 4 who are receiving treatment at week 24 for whom quantitative HCV RNA testing was performed at 24 weeks of treatment.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who had HCV RNA testing ordered or performed.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received counseling regarding use of alcohol at least once within the 12 month reporting period.
• Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were recommended to receive or have received hepatitis A and hepatitis B vaccine series, or who have documented immunity.
• Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) with in the 12 month reporting period.
• Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are prescribed or who have received adjuvant chemotherapy within the 12 month reporting period.
• Oncology: percentage of patients with a diagnosis of breast, colon, or rectal cancer seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.
• Oncology: percentage of patients with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug(s) prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.
• Oncology: percentage of patients with a diagnosis of cancer receiving 3D conformal radiation therapy with documentation in medical record that normal tissue dose constraints were established within five treatment days for a minimum of one tissue.
• Oncology: percentage of patients with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have a documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.
• Oncology: percentage of patients with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care within one month completing treatment.
• Oncology: percentage of patients with a diagnosis of cancer with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.
• Oncology: percentage of visits for patients with a diagnosis of cancer currently receiving intravenous chemotherapy or radiation therapy in which pain intensity is quantified.
• Oncology: percentage of visits for patients with a diagnosis of cancer currently receiving intravenous chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
• Pathology: percentage colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
• Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
• Prenatal testing: percentage of D (Rh) negative, unsensitized patients who gave birth during a 12-month period who receive anti-D immune globulin at 26-30 weeks gestation.
• Prenatal testing: percentage of patients who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit.
• Prostate cancer: percentage of patients with a diagnosis of prostate cancer, at high risk of recurrence, receiving external beam radiotherapy who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).
• Prostate cancer: percentage of patients with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
• Prostate cancer: percentage of patients with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.
• Prostate cancer: percentage of patients with clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.
• Prostate cancer: percentage of patients with prostate cancer receiving external beam radiotherapy to the prostate only who received three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiation therapy (IMRT).
• Prostate cancer: percentage of patients with prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.
• 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 fluroscopy that include documentation of radiation exposure or exposure time.
• Radiology: percentage of final reports for screening mammograms that are classified as BI-RADS® Category 3.
• 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 receive a final BI-RADS® assessment Category of 4 or 5 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 receive a final BI-RADS® assessment Category of 4 or 5 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 BI-RADS® assessment category is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.

Standards for Bipolar Excellence (STABLE) Performance Measures

• Bipolar disorder: percentage of patients with Bipolar I Disorder with depressive symptoms and behaviors who have evidence of use of a mood stabilizing or antimanic agent during the first 12 weeks of pharmacotherapy treatment.
• Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their level-of-functioning in response to treatment.
• Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment.
• Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are provided with education and information about their illness and treatment within 12 weeks of initiating treatment.
• Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms twice within the first 24 weeks of treatment.
• Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who receive at least one screening for hyperglycemia within the initial 16 weeks of treatment.
• Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who received at least one assessment for hyperlipidemia within the initial 16 week period of treatment.
• Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with lithium who have evidence of a lithium serum medication level with 12 weeks of beginning treatment.
• Bipolar disorder: the percentage of patients diagnosed with bipolar disorder who receive an initial assessment that considers the risk of suicide.
• Bipolar disorder: the percentage of patients with bipolar disorder who receive a recommendation for an adjunctive psychosocial intervention, including evidence-based therapies, within 12 weeks of initiating treatment.
• Bipolar disorder: the percentage of patients with bipolar disorder who receive an initial assessment that considers alcohol and chemical substance use.
• Bipolar disorder: the percentage of patients with bipolar disorder who were monitored for weight gain during initial 12 week period of treatment.
• Bipolar disorder: the percentage of patients with Bipolar I Disorder symptoms and behaviors who received monotherapy with an antidepressant agent during the first 12 weeks of treatment.
• Bipolar disorder: the percentage of patients with Bipolar I Disorder with mania/hypomania, mixed or cycling symptoms and behaviors who have evidence of use of pharmacotherapy agent with antimanic properties during the first 12 weeks of treatment.
• Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers alcohol and chemical substance use.
• Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers the risk of suicide.
• Depression: the percentage of patients presenting with depression who were assessed, prior to the initiation of treatment, for the presence of prior or current symptoms and/or behaviors associated with mania or hypomania.

MEDDIC-MS (Medicaid Encounter Data Driven Improvement Core Measure Set). Automated rapid-cycle performance measures for the Medicaid and BadgerCare HMO programs.

• Ambulatory care management of diabetes: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS SSI).
• Ambulatory care management of diabetes: percent of patients with at least one lipid profile test in the look-back period (MEDDIC-MS SSI).
• Ambulatory diabetes care: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS).
• Ambulatory diabetes care: percent of patients with at least one lipid profile (LDL) test in the look-back period (MEDDIC-MS).
• Asthma care: number of enrollees with a diagnosis of asthma (MEDDIC-MS).
• Asthma care: percent of enrollees with a diagnosis of asthma (MEDDIC-MS SSI).
• Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS SSI).
• Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS).
• Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS SSI).
• Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS).
• Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 17 and 28 months (MEDDIC-MS).
• Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 6 and 16 months (MEDDIC-MS).
• Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS SSI).
• Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS).
• Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC MS).
• Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC-MS SSI).
• Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS SSI).
• Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS).
• Cervical cancer detection: percent of women diagnosed with cervical/uterine malignancy among those screened (MEDDIC-MS SSI).
• Cervical cancer detection: percent of women diagnosed with cervical/uterine pre-malignant or malignant lesions among those screened (MEDDIC-MS).
• Cervical cancer detection: percent of women diagnosed with human papillomavirus (HPV) detected among those screened (MEDDIC-MS SSI).
• Cervical cancer detection: percent of women with human papillomavirus (HPV) detected among those screened (MEDDIC-MS).
• Child health: percent of children who received at least one non-EPSDT (non-HealthCheck), well-child examination or at least one non-EPSDT (non-HealthCheck), non-well-child encounter in the look-back period (MEDDIC-MS).
• Childhood immunizations (full coverage): percent of enrolled children who received all of the following by the measure end date: four DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 4 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR; one varicella zoster virus (VZV) vaccination or one MMRV vaccination; three H influenza type B (Hib) vaccinations, three hepatitis B vaccinations (MEDDIC-MS).
• Childhood immunizations (substantial coverage): percent of enrolled children who received all of the following by the measure end date: three DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 3 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR vaccination or one MMRV vaccination, two H influenza type B (Hib) vaccinations, two hepatitis B vaccinations (MEDDIC-MS).
• EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received at least one EPSDT (HealthCheck) examination in the look-back period (MEDDIC-MS).
• EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received seven or more, six, or five comprehensive HealthCheck examinations by the age of two years (MEDDIC-MS).
• General and specialty care: percent of enrollees receiving at least one encounter of care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS).
• General and specialty care: percent of enrollees receiving care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS SSI).
• General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS).
• General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS SSI).
• General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS SSI).
• General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS).
• General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS SSI).
• General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS).
• General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS SSI).
• General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS).
• Inpatient care: all inpatient hospitalizations for maternity-related diagnoses (MEDDIC-MS).
• Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS SSI).
• Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS).
• Inpatient care: all inpatient psychiatric stays (MEDDIC-MS SSI).
• Inpatient care: all inpatient psychiatric stays (MEDDIC-MS).
• Inpatient care: all inpatient stays for hospice, rehabilitation and respite care (MEDDIC-MS).
• Inpatient care: all inpatient stays for hospice, rehabilitation, and respite care (MEDDIC-MS SSI).
• Inpatient care: all inpatient substance abuse stays (MEDDIC-MS SSI).
• Inpatient care: all inpatient substance abuse stays (MEDDIC-MS).
• Inpatient care: all newborn care provided from birth to discharge home (MEDDIC-MS).
• Inpatient care: all surgical stays (MEDDIC-MS SSI).
• Inpatient care: all surgical stays (MEDDIC-MS).
• Maternity care: percent of enrollees who received prenatal care coordination (MEDDIC-MS).
• Maternity care: percent of enrollees who received substance abuse treatment services during the look-back period (MEDDIC-MS).
• Maternity care: percent of enrollees who received testing for HIV during the look-back period (MEDDIC-MS).
• Maternity care: percent of enrollees with delivery by Cesarean section (MEDDIC-MS).
• Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS SSI).
• Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS).
• Mental health: percent of enrollees diagnosed with non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment (MEDDIC-MS SSI).
• Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by mental health specialists (MEDDIC-MS).
• Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS).
• Obesity prevention and treatment: number of encounters with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).
• Obesity prevention and treatment: percent of enrollees who had a non-surgical treatment of obesity (counseling, dietary therapy, exercise program, pharmacological intervention, etc.) with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).
• Obesity prevention and treatment: percent of enrollees who had a screening and/or prevention encounter with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).
• Obesity prevention and treatment: percent of enrollees who had a surgical treatment for obesity with a diagnosis of obesity, morbid obesity, and overweight (MEDDIC-MS).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS).
• Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a specialist mental health or substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI).
• Preventive dental care: percent of enrollees age 18+ years who had at least one preventive dental service during the look-back period (MEDDIC-MS SSI).
• Preventive dental care: percent of patients age 21 years and older who have had at least one preventive dental service in the look-back period (MEDDIC-MS).
• Preventive dental care: percent of patients age 3 to 20 years who have had at least one preventive dental service in the look-back period (MEDDIC-MS).
• Substance abuse: percent of enrollees with substance abuse diagnosis receiving day/outpatient substance abuse treatment (MEDDIC-MS SSI).
• Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS).
• Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by substance abuse specialists (MEDDIC-MS).
• Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had a pharmacological intervention only (MEDDIC-MS).
• Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling and pharmacological intervention (MEDDIC-MS).
• Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling intervention only (MEDDIC-MS).
• Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit and a counseling intervention only (MEDDIC-MS).
• Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit with a counseling and pharmacological intervention (MEDDIC-MS).

Fiscal Year (FY) 2008: Veterans Health Administration (VHA) Performance Measurement System

• Appropriate screening: percent of eligible patients screened annually for depression and if positive PHQ-2 or PHQ-9 result or affirmative response to Question 9, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.
• Appropriate screening: percent of eligible patients screened at required intervals for PTSD and if positive PC-PTSD result, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.
• Breast cancer screening: percent of women age 40 to 49 screened for breast cancer in the past two years.
• Breast cancer screening: percent of women age 40 to 69 screened for breast cancer in the past two years.
• 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.
• 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 patients with a diagnosis of diabetes mellitus having HbA1c less than 7.
• Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus having HbA1c testing performed during the past year.
• Diabetes mellitus: percent of patients with diabetes mellitus and blood pressure less than 130/80 mm Hg.
• Diabetes mellitus: percent of patients with diabetes mellitus having full lipid panel in the past year.
• Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive mono-drug therapy where the regimen includes a thiazide diuretic.
• Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive multi-drug therapy where the regimen includes a thiazide diuretic.
• Infection rate reduction: percent of central line associated bloodstream (CLAB) cases in the intensive care unit (ICU) per month.
• Infection rate reduction: percent of ventilator-associated pneumonia (VAP) infections in the intensive care units (ICUs) per month.
• Influenza immunization: percent of applicable patients age 50 to 64 years receiving influenza immunizations between September 1, 2007 and March 31, 2008 in accordance with defined VHA policy.
• Mental health: percent of eligible patients screened annually for depression.
• Mental health: percent of eligible patients screened at required intervals for PTSD.
• Mental health: the percentage of patients who were diagnosed with a new episode of depression and treated with antidepressant medication, and who had at least three follow-up practitioner contacts for medication management during the 84-day (12 week) acute treatment phase.
• Mental health: the percentage of patients who were diagnosed with a new episode of depression, and treated with antidepressant medication, and who remained an antidepressant drugs for at least 84 treatment days (12 weeks) after the Index Prescription Date.
• Pneumococcal immunization: percent of applicable patients receiving pneumococcal immunization.
• Seamless continuum of care: 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.
• Seamless continuum of care: percent of patients screened positive for depression symptoms with PHQ-2 or PHQ-9 or affirmative answer to Question 9 of the PHQ-9 who have timely triage.
• 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.