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December 29, 2008

Agency for Healthcare Research and Quality

Birth trauma -- injury to neonate: rate per 1,000 liveborn births. This updates a previously published measure summary.

Complications of anesthesia: rate per 1,000 surgery discharges with an operating room procedure. This updates a previously published measure summary.

Death among surgical inpatients with serious treatable complications: deaths per 1,000 discharges. This updates a previously published measure summary.

Death in low-mortality DRGs: in-hospital deaths per 1,000 discharges. This updates a previously published measure summary.

Decubitus ulcer: rate per 1,000 discharges. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 Cesarean deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 instrument-assisted vaginal deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 vaginal deliveries without instrument assistance. This updates a previously published measure summary.

Postoperative hip fracture: rate per 1,000 surgical discharges. This updates a previously published measure summary.

Postoperative physiologic and metabolic derangement: rate per 1,000 elective surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative pulmonary embolism or deep vein thrombosis: rate per 1,000 surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative respiratory failure: rate per 1,000 elective surgical discharges with an operating room procedure. This updates a previously published measure summary.

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

December 22, 2008

Ambulatory Surgery Center (ASC) Quality Collaboration

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

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

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

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

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

American Podiatric Medical Association

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

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

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

Physician Consortium for Performance Improvement®

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

December 15, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

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

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

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

Neonatal infections: percentage of babies of birth weight less than 1000 grams admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.

Neonatal infections: percentage of babies of greater than or equal to 1000 grams birth weight, admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.

Neonatal infections: percentage of live babies born at the reporting hospital who develop blood stream and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.

Neonatal infections: percentage of live babies of greater than or equal to 37 weeks estimated gestational age at birth (GA) born at the reporting hospital who develop a blood and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.

Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of greater than or equal to 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.

Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of less than 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.

Occupational exposure: percentage of reported non-parenteral exposures sustained by staff, during the 6 month time period.

Occupational exposure: percentage of reported parenteral exposures sustained by staff, during the 6 month time period.

December 8, 2008

Australian Council on Healthcare Standards

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

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

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

VHA, Inc.

Sepsis: median time to initiation of a recommended broad-spectrum antibiotic following severe sepsis/septic shock identification.

Sepsis: median time to initiation of Vancomycin (or Linezolid) following severe sepsis/septic shock identification.

Sepsis: percent of eligible patients with severe sepsis or septic shock who were started on activated protein C (APC) within 48 hours following severe sepsis/septic shock identification.

Sepsis: percent of patients with septic shock who received steroids within 24 hours following septic shock identification.

Sepsis: percent of patients with severe sepsis/septic shock AND an organism other than MRSA or MRSE who had Vancomycin (or Linezolid) discontinued within 72 hours following severe sepsis/septic shock identification.

Sepsis: percent of patients with severe sepsis/septic shock who had 2 sets of blood cultures collected within 24 hours following severe sepsis/septic shock identification.

Sepsis: percent of patients with severe sepsis/septic shock who received a recommended broad-spectrum antibiotic within 24 hours following severe sepsis/septic shock identification.

Sepsis: percent of patients with severe sepsis/septic shock who received Vancomycin (or Linezolid) within 24 hours following severe sepsis/septic shock identification.

Sepsis: percent of patients with severe sepsis/septic shock who were assessed for activated protein C (APC) eligibility within 24 hours following severe sepsis/septic shock identification.

December 1, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

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

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

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

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

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

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

November 24, 2008

Agency for Healthcare Research and Quality

Abdominal aortic aneurysm (AAA) repair: mortality rate. This updates a previously published measure summary.

Abdominal aortic aneurysm (AAA) repair: volume. This updates a previously published measure summary.

Acute myocardial infarction (AMI): mortality rate, without transfer cases. This updates a previously published measure summary.

Acute myocardial infarction (AMI): mortality rate. This updates a previously published measure summary.

Acute stroke: mortality rate. This updates a previously published measure summary.

Carotid endarterectomy (CEA): mortality rate. This updates a previously published measure summary.

Carotid endarterectomy (CEA): volume. This updates a previously published measure summary.

Cholecystitis/cholelithiasis: laparoscopic cholecystectomy rate. This updates a previously published measure summary.

Congestive heart failure (CHF): mortality rate. This updates a previously published measure summary.

Coronary artery bypass graft (CABG): volume. This updates a previously published measure summary.

Coronary artery disease: bilateral cardiac catheterization rate. This updates a previously published measure summary.

Coronary artery disease: coronary artery bypass graft (CABG) area rate. This updates a previously published measure summary.

Coronary artery disease: coronary artery bypass graft (CABG) mortality rate. This updates a previously published measure summary.

Coronary artery disease: percutaneous transluminal coronary angioplasty (PTCA) area rate. This updates a previously published measure summary.

Craniotomy: mortality rate. This updates a previously published measure summary.

Esophageal cancer: esophageal resection mortality rate. This updates a previously published measure summary.

Esophageal resection: volume. This updates a previously published measure summary.

Gastrointestinal (GI) hemorrhage: mortality rate. This updates a previously published measure summary.

Hip fracture: mortality rate. This updates a previously published measure summary.

Hip osteoarthrosis: hip replacement mortality rate. This updates a previously published measure summary.

Hysterectomy: hysterectomy area rate. This updates a previously published measure summary.

Incidental appendectomy: incidental appendectomy among the elderly rate. This updates a previously published measure summary.

Laminectomy or spinal fusion: laminectomy or spinal fusion area rate. This updates a previously published measure summary.

Maternity care: Cesarean delivery rate. This updates a previously published measure summary.

Maternity care: primary Cesarean delivery rate. This updates a previously published measure summary.

Maternity care: vaginal birth after Cesarean (VBAC) rate, all. This updates a previously published measure summary.

Maternity care: vaginal birth after Cesarean (VBAC) rate, uncomplicated. This updates a previously published measure summary.

Pancreatic cancer: pancreatic resection mortality rate. This updates a previously published measure summary.

Pancreatic resection: volume. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): mortality rate. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): volume. This updates a previously published measure summary.

Pneumonia: mortality rate. This updates a previously published measure summary.

November 17, 2008

Institute for Clinical Systems Improvement

Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record. This updates a previously published measure summary.

Preoperative evaluation: percentage of patients with a preoperative health history and physical examination completed prior to the day of scheduled procedure. This updates a previously published measure summary.

Routine prenatal care: percentage of all identified preterm birth (PTB) modifiable risk factors assessed that receive an intervention. This updates a previously published measure summary.

Routine prenatal care: percentage of pregnant women who report to have received counseling and education by the 28th week visit. This updates a previously published measure summary.

Routine prenatal care: percentage of vaginal birth after cesarean (VBAC) eligible women who receive general education describing risks and benefits of VBAC (e.g., the American College of Obstetricians and Gynecologists pamphlet on VBAC). This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

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

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

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

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

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

Geriatrics: percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

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

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

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

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

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

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

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

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

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

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

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

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

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

November 10, 2008

Australian Council on Healthcare Standards

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

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

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

General surgery: percentage of patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention, 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.

Obstetrics: percentage of deliveries with birth weight less than 2750g at 40 weeks gestation or beyond.

Obstetrics: percentage of high risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis.

Obstetrics: percentage of inborn term babies transferred/admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality.

Obstetrics: percentage of selected primipara sustaining a perineal tear and NO episiotomy.

Obstetrics: percentage of selected primipara undergoing caesarean section.

Obstetrics: percentage of selected primipara undergoing episiotomy and NO perineal tear while giving birth vaginally.

Obstetrics: percentage of selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally.

Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for fourth degree tear.

Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for third degree tear.

Obstetrics: percentage of selected primipara who have a spontaneous vaginal birth.

Obstetrics: percentage of selected primipara who undergo an instrumental vaginal birth.

Obstetrics: percentage of selected primipara who undergo induction of labour.

Obstetrics: percentage of selected primipara with an intact perineum.

Obstetrics: percentage of serious adverse events that are addressed within a peer review process.

Obstetrics: percentage of term babies born with an Apgar score of less than 7 at five minutes post delivery.

Obstetrics: percentage of women delivering vaginally following a previous primary caesarean section.

Obstetrics: percentage of women having a general anaesthetic for caesarean section.

Obstetrics: percentage of women who give birth vaginally who require a blood transfusion during the same admission.

Obstetrics: percentage of women who receive an appropriate prophylactic antibiotic at the time of caesarean section.

Obstetrics: percentage of women who undergo a caesarean section who require a blood transfusion during the same admission.

Orthopaedic surgery: percentage of patients undergoing primary total hip joint replacement (THJR) having a postoperative in hospital infection, during the 6 month time period.

Otolaryngology: percentage of patients who have a significant reactionary haemorrhage following tonsillectomy, during the 6 month time period.

Paediatric 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.

Plastic surgery: percentage of completely excised malignant skin tumors, during the 6 month time period.

Urology: average number of patient days (from the first day after surgery) for all patients having a transurethral resection (TUR) for benign prostatomegaly (excluding patients having other procedures), during the 6 month time period.

Urology: average operating time (minutes) for all patients undergoing a transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.

Urology: percentage of patients having a transurethral resection (TUR) for benign prostatomegaly, who have a blood transfusion (intra-operatively or post-operatively) within the same admission, during the 6 month time period.

Urology: percentage of patients having an unplanned readmission within 28 days of discharge following transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.

Vascular surgery: percentage of patients having a carotid endarterectomy who have a stroke within the same admission, during the 6 month time period.

Vascular surgery: percentage of patients having an elective abdominal aortic aneurysm (AAA) repair, who die within the same admission, during the 6 month time period.

November 3, 2008

American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Australian Council on Healthcare Standards

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in femoral-popliteal bypass procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in the donor incision site) in coronary artery bypass graft (CABG) procedures performed (involving chest and donor incisions), during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.

Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in femoral-popliteal bypass procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.

Surgical site infection: percentage of superficial incisional surgical site infections (SSIs)(in the donor incision site) in coronary artery bypass graft (CABG) procedures performed (involving chest and donor incisions), during the 6 month time period.

Surgical site infection: percentage of superficial surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.

Joint Commission, The

Hospital-based inpatient psychiatric services: the percentage of patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan created.

Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan provided to the next level of care clinician or entity.

Hospital-based inpatient psychiatric services: the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

Hospital-based inpatient psychiatric services: the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.

October 27, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

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

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

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

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

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

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.

Mental health inpatient: percentage of inpatient separations having seclusion, during the 6 month time period.

Mental health inpatient: percentage of inpatient separations with a diagnosis on hospital discharge, which is recorded in the medical record, during the 6 month time period.

Mental health inpatient: percentage of inpatient separations with an individual care plan, which is constructed and regularly reviewed with the consumer, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least 1 episode of seclusion, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least 2 episodes of seclusion, in an admission or in a 1 month period of an extended admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having at least one episode of physical restraint, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion for more than 4 hours in 1 episode, in an admission, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion who experience major complications while in seclusion, during the 6 month time period.

Mental health inpatient: percentage of inpatients having seclusion who were not reviewed by sight, by a medical practitioner or nurse on at least a half-hourly basis, during the 6 month time period.

Mental health inpatient: percentage of inpatients in an acute unit with a length of stay greater than 30 days, during the 6 month time period.

Mental health inpatient: percentage of inpatients on 3 or more psychotropic medications from 1 sub-group category specified, at the time of discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a discharge summary or letter, at the time of discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a final discharge summary recorded in the medical record within 2 weeks of hospital discharge, during the 6 month time period.

Mental health inpatient: percentage of inpatients who have a multidisciplinary review recorded every 3 months, during the 6 month time period.

Mental health inpatient: percentage of inpatients with a complete documented physical examination within 48 hours of admission, during the 6 month time period.

Mental health inpatient: percentage of patients allocated a diagnosis within 24 hours of admission, during the 6 month time period.

Mental health inpatient: percentage of patients experiencing major medical complications while undergoing electro convulsive therapy (ECT), during the 6 month time period.

Mental health inpatient: percentage of patients undergoing more than 12 treatments of electro convulsive therapy (ECT), during the 6 month time period.

Mental health inpatient: percentage of voluntary inpatient admissions, during the 6 month time period.

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.

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.

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.

October 20, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

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

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.

Refractive surgery: percentage of patients having a complication (medical or surgical) within 28 days following excimer laser surgery, during the 6 month time period.

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

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

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

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

Retinal detachment surgery: percentage of patients having an unplanned reoperation on the same eye within 28 days, following retinal detachment surgery, during the 6 month time period.

Retinal detachment surgery: percentage of patients with a total length of stay (LOS) greater than 4 days, following retinal detachment surgery, during the 6 month time period.

Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, due to endophthalmitis in the operated eye, during the 6 month time period.

Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, during the 6 month time period.

Skin tumour pathology (biopsy book): percentage of histopathology specimens taken with a skin tumour working diagnosis, during the 6 month time period.

National Committee for Quality Assurance

Adolescent well-care visits: percentage of members who were 12 through 21 years of age who had at least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner during the measurement year. This updates a previously published measure summary.

Frequency of ongoing prenatal care: percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received less than 21%, 21% to 40%, 41% to 60%, 61% to 80%, or greater than or equal to 81% of the expected number of prenatal care visits. This updates a previously published measure summary.

Well-child visits in the first 15 months of life: percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a primary care practitioner (PCP) during their first 15 months of life: zero, one, two, three, four, five, six or more. This updates a previously published measure summary.

Well-child visits in the third, fourth, fifth and sixth years of life: percentage of members who were three to six years of age during the measurement year who received one or more well-child visits with a primary care practitioner (PCP) during the measurement year. This updates a previously published measure summary.

October 13, 2008

Australian Council on Healthcare Standards

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

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

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

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

Rehabilitation medicine: percentage of inpatients for whom there is documented evidence of a functional assessment within 72 hours prior to cessation of an inpatient rehabilitation program, during the 6 month time period.

Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is a documented established multidisciplinary rehabilitation plan within 7 days of patient admission, during the 6 month time period.

Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is documented evidence of a functional assessment within 72 hours of patient admission, during the 6 month time period.

Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and been discharged to their pre-episode form of accommodation, or a form of accommodation that allows great independence, during the 6 month time period.

Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and for whom there is documented evidence of functional gain, during the 6 month time period.

Rehabilitation medicine: percentage of separations for which there is an appropriate discharge plan for a patient, during the 6 month time period.

Physician Consortium for Performance Improvement®

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

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

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

October 6, 2008

Australian Council on Healthcare Standards

Oral health - children: percentage of deciduous teeth extracted (for pathological reasons) within 6 months following pulpotomy treatment, during the time period under study.

Oral health - children: percentage of teeth requiring re-treatment (restoration, endodontic or extraction, but not including Pit & Fissure Sealants) within 24 months of the initial fissure sealant treatment.

Oral health - children: percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment.

Oral health: percentage of attendances for complications within 7 days of routine extraction, during the time period under study.

Oral health: percentage of attendances for complications within 7 days of surgical extraction, during the time period under study.

Oral health: percentage of completed courses of endodontic treatment on the same tooth within 6 months of initial treatment, during the time period under study.

Oral health: percentage of new patients aged 65 years and over who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged 65 years and over who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged under 18 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients aged under 18 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 18 to 24 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 18 to 24 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 25 to 64 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.

Oral health: percentage of new patients in the age bracket 25 to 64 years who had intraoral films taken as part of the first general course of care, during the time period under study.

Oral health: percentage of patients with completed and updated medical history, during the time period under study.

Oral health: percentage of patients with completed charting at initial assessment for general course of care, during the time period under study.

Oral health: percentage of radiographs (bite-wing) that meet all of the 6 criteria (as outlined), during the time period under study.

Oral health: percentage of same denture type (full or partial) and same arch remade within 12 months, during the time period under study.

Oral health: percentage of teeth extracted within 12 months of completing a course of endodontic treatment, during the time period under study.

Oral health: percentage of teeth retreated between 1 and 6 months of completing a course of endodontic treatment, during the time period under study.

Oral health: percentage of teeth retreated within 6 months of an episode of restorative treatment, during the time period under study.

September 29, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

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

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

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

Microbiology: percentage of validated CSF results from ED for microscopy (+/- gram stain) with a turnaround time (collected to validated time) less than 60 minutes, during the 1 to 2 month time period.

Microbiology: percentage of validated CSF results from ED with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period.

Physician Consortium for Performance Improvement®

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

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

September 22, 2008

American College of Rheumatology

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

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

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

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

Australian Council on Healthcare Standards

Radiation oncology: percentage of curative megavoltage radiotherapy courses provided, where CT planning was utilised, during the 6 month time period.

Radiation oncology: percentage of patients receiving megavoltage radiotherapy using multi-leaf collimators (MLCs), during the 6 month time period.

Radiation oncology: percentage of patients receiving radiotherapy, who have a letter on file to the referring doctor and general practitioner, regarding the current radiotherapy course, during 1 week in May or November.

Radiation oncology: percentage of patients waiting more than 14 days from the date 'ready for care', to the date of commencing radiotherapy, during 1 week in May or November.

Radiation oncology: percentage of patients who had radiotherapy for breast conservation (pT 1-3, any nodal staging, M0), during the 6 month time period, who had complete follow-up.

Radiation oncology: percentage of patients who had radiotherapy for glottic cancer (T1-2 N0 M0), during the 6 month time period, who had complete follow-up.

Radiation oncology: percentage of patients who have informed consent recorded in the medical record before receiving radiotherapy, during 1 week in May or November.

Radiation oncology: percentage of patients who receive curative chemoradiotherapy for squamous cell carcinoma (SCC) of the cervix in the definitive or the post-operative setting, during the 6 month time period.

Radiation oncology: percentage of patients with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, hypopharynx and larynx who wait longer than 6 weeks from their definitive surgery to commencing their radiotherapy, during the 6 month time period.

September 15, 2008

Australian Council on Healthcare Standards

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.

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.

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.

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.

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.

September 8, 2008

Australian Council on Healthcare Standards

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.

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.

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.

September 1, 2008

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

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

Institute for Clinical Systems Improvement

Colorectal cancer screening: percentage of African American patients age 45 and older who are up-to-date with colorectal cancer screening. This updates a previously published measure summary.

Colorectal cancer screening: percentage of patients age 50 and older who are up-to-date with colorectal cancer screening. This updates a previously published measure summary.

Diagnosis and management of type 2 diabetes mellitus: frequency of low-density lipoprotein (LDL) cholesterol values in adult patients with type 2 diabetes mellitus by category: less than 100 mg/dL, 100-130 mg/dL, greater than 130 mg/dL, incalculable, untested. This updates a previously published measure summary.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients who have had a screen for A1C, LDL less than 100 mm/dL, blood pressure less than 130/80, who are current documented non-smokers and take daily aspirin. This updates a previously published measure summary.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with A1C measured in the last six months. This updates a previously published measure summary.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with eye exam documented within last 12 months. This updates a previously published measure summary.

Diagnosis and management of type 2 diabetes mellitus: percentage of adult patients with type 2 diabetes mellitus with microalbumin tested within last 12 months. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients who commit suicide at any time while under depression management with a primary care physician.

Major depression in adults in primary care: percentage of patients who have a depression follow-up contact within three months of initiating treatment. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients who have had a response to treatment at six months (+/- 30 days) after initiating treatment i.e., have had a Patient Health Questionnaire (PHQ-9) score decreased by 50% from initial score at six months (+/- 30 days).

Major depression in adults in primary care: percentage of patients who have reached remission at six months (+/- 30 days) after initiating treatment, i.e., have any PHQ-9 score less than five after six months (+/- 30 days).

Major depression in adults in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as Patient Health Questionnaire [PHQ-9]) within three months of initiating treatment. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients with a new diagnosis of major depression, with documentation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria within the three months prior to initial diagnosis. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients with diabetes with documentation of screening for depression. This updates a previously published measure summary.

Palliative care: percentage of adult patients with a progressive, debilitating disease who have a palliative care plan documented in the medical record.

August 25, 2008

Australian Council on Healthcare Standards

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

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

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

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

Patient deaths: percentage of patient deaths addressed within a clinical audit process, 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.

National Committee for Quality Assurance

Fall risk management: the percentage of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by an MAO practitioner in the past 12 months and who received fall risk intervention from their current practitioner.

Fall risk management: the percentage of Medicare members 75 years of age and older or who are 65 to 74 years of age with balance or walking problems or a fall in the past 12 months who were seen by an MAO practitioner in the past 12 months and who discussed fall or problems with balance or walking with their current practitioner.

Management of urinary incontinence in older adults: percentage of Medicare members 65 years of age and older who reported having a urine leakage problem in the past six months and who discussed their urinary leakage problem with their current practitioner. This updates a previously published measure summary.

Management of urinary incontinence in older adults: percentage of Medicare members 65 years of age and older who reported having a urine leakage problem in the past six months and who received treatment for their current urine leakage problem. This updates a previously published measure summary.

Osteoporosis testing in older women: the percentage of female Medicare members 65 years of age and over who report ever having received a bone density test to check for osteoporosis.

Physical activity in older adults: percentage of Medicare members 65 years of age and older who had a doctor's visit in the past 12 months and who received advice to start, increase or maintain their level of exercise or physical activity. This updates a previously published measure summary.

Physical activity in older adults: percentage of Medicare members 65 years of age and older who had a doctor's visit in the past 12 months and who spoke with a doctor or other health provider about their level of exercise or physical activity. This updates a previously published measure summary.

The Medicare Health Outcomes Survey: percentage of members whose health status was "better," "the same" or "worse than expected" at the end of a two-year period. This updates a previously published measure summary.

August 18, 2008

Australian Council on Healthcare Standards

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

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

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

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

Institute for Clinical Systems Improvement

Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication. This updates a previously published measure summary.

Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication. This updates a previously published measure summary.

Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

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

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

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

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

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

End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times (every 4 months) during the 12 month reporting period.

August 11, 2008

STABLE Project National Coordinating Council

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.

August 4, 2008

Australian Council on Healthcare Standards

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.

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.

Press Ganey Associates, Inc.

Home health care satisfaction: mean section score for "Arranging Your Home Health Care" questions on Home Health Care Survey. This updates a previously published measure summary.

Home health care satisfaction: mean section score for "Managing Your Home Health Care" questions on Home Health Care Survey. This updates a previously published measure summary.

Home health care satisfaction: mean section score for "Nurses" questions on Home Health Care Survey. This updates a previously published measure summary.

Home health care satisfaction: mean section score for "Overall Ratings" questions on Home Health Care Survey. This updates a previously published measure summary.

Home health care satisfaction: mean section score for "Personal Issues" questions on Home Health Care Survey.

July 28, 2008

Australian Council on Healthcare Standards

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

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

Morbidity of radiological procedures: percentage of patients experiencing iodinated contrast extravasation requiring medical review during an IV contrast enhanced CT procedure, during the 6 month period.

Morbidity of radiological procedures: percentage of patients undergoing percutaneous transpleural biopsy of the lung or mediastinum, for whom there is documented evidence of pneumothorax and/or haemothorax requiring intervention following the procedure, during the 6 month period.

Morbidity of radiological procedures: percentage of peripheral embolic complications during angioplasty of the arteries in upper or lower limbs, during the 6 month period.

Morbidity of radiological procedures: percentage of puncture site complications during or following angiography, during the 6 month period.

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.

HealthPartners

Cervical cancer screening: percentage of women ages 21 years and older in the measurement year screened in accordance with evidence-based standards.

Depression: percentage of members ages 18 years and older diagnosed with a new episode of depression, treated with antidepressant medication and optimally managed.

Preventive services: percentage of adult enrolled members ages 19 years and older that are up-to-date for all appropriate preventive services.

Preventive services: percentage of enrolled members ages less than or equal to 18 years who are up-to-date for all appropriate preventive services.

July 21, 2008

National Committee for Quality Assurance

Adults' access to preventive/ambulatory health services: percentage of members who had an ambulatory or preventive-care visit. This updates a previously published measure summary.

Children and adolescents' access to primary care practitioners: percentage of members who had a visit with a primary care practitioner. This updates a previously published measure summary.

Dental care: percentage of members 2 through 21 years of age who had at least one dental visit during the measurement year. This updates a previously published measure summary.

Engagement of alcohol and other drug (AOD) treatment: percentage of adolescent and adult members who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. This updates a previously published measure summary.

Initiation of alcohol and other drug (AOD) treatment: percentage of adolescent and adult members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of diagnosis. This updates a previously published measure summary.

Postpartum care: percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. This updates a previously published measure summary.

Timeliness of prenatal care: percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. This updates a previously published measure summary.

Veterans Health Administration

Alcohol misuse: percent of patients screened for alcohol misuse with AUDIT-C who meet or exceed a threshold score of 5 who have timely brief alcohol counseling.

Depression: percent of eligible patients screened annually for depression and if positive PHQ-2 or PHQ-9 result or affirmative response to Question 9, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.

Depression: percent of patients screened positive for depression symptoms with PHQ-2 or PHQ-9 or affirmative answer to Question 9 of the PHQ-9 who have timely triage.

Infection rate reduction: number of central line associated bloodstream (CLAB) infections per 1,000 central line patient days.

Infection rate reduction: number of ventilator-associated pneumonia (VAP) infections per 1,000 ventilator days.

Post-traumatic stress disorder (PTSD): percent of eligible patients screened at required intervals for PTSD and if positive PC-PTSD result, who have Suicide Ideation/Behavioral Evaluation completed within 24 hours.

July 14, 2008

Institute for Clinical Systems Improvement

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. This updates a previously published measure summary.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis who had strep screen testing. This updates a previously published measure summary.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than seven days and who receive an antibiotic. This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

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.

July 7, 2008

Veterans Health Administration

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.

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.

Pneumococcal immunization: percent of applicable patients receiving pneumococcal immunization.

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.

June 30, 2008

National Committee for Quality Assurance

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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.

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. This updates a previously published measure summary.

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 This updates a previously published measure summary.

June 23, 2008

National Committee for Quality Assurance

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Attention-deficit/hyperactivity disorder (ADHD) (continuation maintenance phase): percentage of members 6 to 12 years of age with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Pneumonia vaccination status: percentage of Medicare members 65 years of age and older who have ever received a pneumococcal vaccination. This updates a previously published measure summary.

Smoking cessation: percentage of members 18 years and older who were current smokers, who were seen by a health plan practitioner during the measurement year for whom discussed or were recommended smoking cessation methods or strategies. This updates a previously published measure summary.

Smoking cessation: percentage of members 18 years of age and older who are current smokers, who were seen by a health plan practitioner during the measurement year and who received advice to quit smoking. This updates a previously published measure summary.

Smoking cessation: percentage of members 18 years of age and older who are current smokers, who were seen by a health plan practitioner during the measurement year for whom discussed or were recommended smoking cessation medications. This updates a previously published measure summary.

June 16, 2008

Physician Consortium for Performance Improvement®

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.

June 9, 2008

Veterans Health Administration

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.

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.

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.

June 2, 2008

HealthPartners

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).

Physician Consortium for Performance Improvement®

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

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

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

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

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

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

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

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

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

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

May 26, 2008

National Committee for Quality Assurance

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child got care quickly. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' satisfaction with care: parents' or guardians' ratings of the specialist their child saw most often. This updates a previously published measure summary.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health care. This updates a previously published measure summary.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health plan. This updates a previously published measure summary.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's personal doctor. This updates a previously published measure summary.

May 19, 2008

National Committee for Quality Assurance

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy to get needed care. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors communicated well. This updates a previously published measure summary.

Health plan members' experiences: percentage of adult health plan members who reported how often their health plans handled their claims quickly and correctly. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan's customer service. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

Health plan members' satisfaction with care: adult health plan members' ratings of the specialist they saw most often. This updates a previously published measure summary.

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan. This updates a previously published measure summary.

Health plan members' satisfaction with care: adult health plan members' ratings of their personal doctor. This updates a previously published measure summary.

May 12, 2008

National Committee for Quality Assurance

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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). This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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. This updates a previously published measure summary.

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). This updates a previously published measure summary.

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. This updates a previously published measure summary.

May 5, 2008

Physician Consortium for Performance Improvement®

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

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

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

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

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

Veterans Health Administration

Acute coronary syndrome (ACS): percent of patients hospitalized for ACS with cardiac symptoms prior to or on arrival to the acute setting who had an ECG performed 15 minutes prior to arrival in acute setting or within 10 minutes after arrival. This updates a previously published measure summary.

Acute coronary syndrome (ACS): percent of patients hospitalized with ACS found to be high or moderate-high risk patients with cardiology involvement in care within 24 hours of acute arrival or if AMI as inpatient, within 24 hours of initial ECG or first positive troponin whichever is earlier. This updates a previously published measure summary.

Acute coronary syndrome (ACS): percent of patients with first troponin result returned within 60 minutes of order time. This updates a previously published measure summary.

Appropriate screening: percent of eligible patients screened annually for alcohol misuse with AUDIT-C. This updates a previously published measure summary.

Hypertension: percent of eligible patients with an active diagnosis of hypertension whose most recent blood pressure recording was less than 140/90 mm Hg. This updates a previously published measure summary.

Ischemic heart disease (IHD): percent of patients discharged with AMI, CABG, PTCA (inpatient or outpatient), or with ischemic vascular disease who have had a full lipid panel in the past year and LDL-C less than 100 on most recent test in past year. This updates a previously published measure summary.

April 28, 2008

Institute for Clinical Systems Improvement

Diagnosis and treatment of otitis media in children: percentage of caregivers receiving education on the symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media. This updates a previously published measure summary.

Diagnosis and treatment of otitis media in children: percentage of patients with a diagnosis of acute otitis media who were prescribed amoxicillin. This updates a previously published measure summary.

Veterans Health Administration

Homeless: percent of eligible homeless veterans with an intake interview who receive timely MH or SUD specialty services. This updates a previously published measure summary.

Homeless: percent of homeless veterans entering a homeless program who receive timely MH or SUD specialty services. This updates a previously published measure summary.

Homeless: percent of homeless veterans entering a homeless residential program who receive timely primary care services. This updates a previously published measure summary.

Homeless: percent of veterans discharged from one of three types of homeless residential programs who receive timely MH or SUD specialty follow-up. This updates a previously published measure summary.

Mental Health Intensive Case Management (MHICM): percent of psychosis patients projected as requiring MHICM who receive outpatient care in MHICM. This updates a previously published measure summary.

Mental health: percent of patients beginning a new episode of treatment for substance use disorder (SUD) who maintain continuous treatment involvement for at least 90 days after qualifying date. This updates a previously published measure summary.

Waiting times - clinic: percent of outpatients seen in primary care at the facility in the previous 24 months who answer 'yes' to the question, "Did you get an appointment when you wanted one?" on the SHEP survey. This updates a previously published measure summary.

Waiting times - clinic: percent of outpatients who have not been seen in primary care at the facility in the previous 24 months who answer 'yes' to the question, "Did you get an appointment when you wanted one?" on the SHEP survey. This updates a previously published measure summary.

Waiting times - provider: percent of outpatients who report waiting for a provider 20 minutes or less in the Survey of Healthcare Experiences of Patients (SHEP). This updates a previously published measure summary.

April 21, 2008

Veterans Health Administration

Breast cancer screening: percent of women age 50 to 69 screened in the past two years for breast cancer. This updates a previously published measure summary.

Cervical cancer screening: percent of women age 21 to 64 screened for cervical cancer in the past three years. This updates a previously published measure summary.

Colon cancer screening: percent of patients receiving appropriate colorectal cancer screening. This updates a previously published measure summary.

Diabetes mellitus: percent of eligible patients with diabetes mellitus having a retinal exam by an Eye Care Specialist, timely, as indicated by disease. This updates a previously published measure summary.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus having hemoglobin A1c (HgbA1c) greater than 9 or not done during the past year. This updates a previously published measure summary.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus who have had a full lipid panel during the past year and the most recent LDL-C is less than 100 mg/dL. This updates a previously published measure summary.

Diabetes mellitus: percent of patients with a diagnosis of diabetes mellitus with blood pressure less than 140/90. This updates a previously published measure summary.

Influenza immunization: percent of applicable patients 65 years and older receiving influenza immunizations between September 1, 2007 and March 31, 2008 in accordance with defined VHA policy. This updates a previously published measure summary.

Veteran satisfaction: percent of patients reporting the overall quality of Veterans Administration (VA) ambulatory care as very good or excellent on the SHEP Outpatient Survey. This updates a previously published measure summary.

Veteran satisfaction: percent of patients reporting the overall quality of Veterans Administration (VA) inpatient care as very good or excellent on the SHEP Inpatient Survey. This updates a previously published measure summary.

April 14, 2008

Agency for Healthcare Research and Quality

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

Decubitus ulcer: rate per 1,000 eligible admissions.

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

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

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

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

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

Pediatric heart surgery: volume.

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

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

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

Postoperative sepsis: rate per 1,000 eligible admissions.

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

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

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

April 7, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo hysterectomy who receive thromboprophylaxis, during the 6 month time period.

Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo pelvic floor surgery who receive thromboprophylaxis, during the 6 month time period.

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

Urogynaecology: percentage of patients receiving injury to major viscus with repair, during a pelvic floor repair procedure subsequently up to 2 weeks post-operatively, during the 6 month time period.

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

March 31, 2008

Australian Council on Healthcare Standards

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

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

Mental health community: percentage of consumers or nominated carers 3 or more face-to-face contacts within a 7 day period.

Mental health community: percentage of consumers or nominated carers with greater than 24 treatment days over a three month period.

Mental health community: percentage of consumers who were admitted to the hospital for psychiatric reasons (by that service) once or more in the first year of treatment.

Mental health community: percentage of registered consumers seen face-to-face by the community service, during the 6 month time period.

Institute for Clinical Systems Improvement

Diagnosis of breast disease: percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7 to 10 days. This updates a previously published measure summary.

March 24, 2008

Agency for Healthcare Research and Quality

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

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

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

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

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

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

March 17, 2008

Physician Consortium for Performance Improvement®

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

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

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

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

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

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

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

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

March 10, 2008

HealthPartners

Coronary artery disease (CAD): percentage of members with CAD who have optimally managed modifiable cardiovascular risk factors (LDL cholesterol, blood pressure control, daily aspirin use, documented non-tobacco use). This updates a previously published measure summary.

Diabetes mellitus: percentage of members with diabetes (Type I and Type II) who have optimally managed modifiable cardiovascular risk factors (HbA1c, LDL cholesterol, blood pressure control, aspirin use and documented non-tobacco use). This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

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

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

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

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

March 3, 2008

Centers for Medicare & Medicaid Services/The Joint Commission

Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital.

Joint Commission, The

Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization.

Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization.

Children's asthma care: percent of pediatric asthma inpatients with documentation that they or their caregivers were given a written Home Management Plan of Care (HMPC) document.

Physician Consortium for Performance Improvement®

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

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

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

February 25, 2008

Centers for Medicare & Medicaid Services

End stage renal disease (ESRD): percentage of adult continuous ambulatory peritoneal dialysis (CAPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.0 and a weekly creatinine clearance (CrCl) of at least 60 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult continuous cycling peritoneal dialysis (CCPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.1 and a weekly creatinine clearance (CrCl) of at least 63 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) or peritoneal dialysis (PD) patients receiving Epoetin therapy with documented mean hemoglobin (Hgb) of 11-12 g/dL (110-120 g/L) during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients for whom delivered HD dose was calculated using formal urea kinetic modeling or Daugirdas II during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients whose average delivered dose of HD was a single-pool Kt/V (spKt/V) greater than or equal to 1.2 during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation and serum ferritin concentration result every three months. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during a three-month period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the study months. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with documented monthly adequacy measurements (urea reduction ratio [URR] or single-pool Kt/V [spKt/V]) during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis patients who were dialyzed through an arterial venous (AV) graft and whose AV graft was routinely surveyed (screened) for the presence of stenosis during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult nightly intermittent peritoneal dialysis (NIPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.2 and a weekly creatinine clearance (CrCl) of at least 66 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult patients who were dialyzed with a chronic catheter continuously for 90 days or longer prior to the last hemodialysis (HD) session during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during the six-month study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least two documented transferrin saturation and serum ferritin concentration results over the six-month study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the two-month periods during the six-month study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with total solute clearance for urea and creatinine measured at least once in a 6 month time period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with weekly Kt/V_urea and creatinine clearance (CrCl) calculated in a standard way. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of incident adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of prevalent adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period. This updates a previously published measure summary.

February 18, 2008

Child and Adolescent Health Measurement Initiative

Ask about parental concerns (developmental surveillance): proportion of children whose parents were asked by their child's health care provider if they have concerns about their child's learning, development and behavior.

Assessment of psychosocial well-being of parent(s) in the family: average percentage of recommended topics assessed.

Assessment of psychosocial well-being of parent(s) in the family: proportion of children whose parents were assessed for one or more topics related to psychosocial well-being.

Effect of care provided on parental confidence: proportion of children whose parents reported care had a positive influence on their confidence in parenting their child and managing their responsibilities.

Follow-up for children at risk for delays: proportion of children who were determined to be at significant risk for developmental, behavioral, or social delays who received some level of follow-up health care.

Health information: proportion of children whose parents received all health information.

Helpfulness of care provided to parents: proportion of children whose parents reported care provided was helpful or very helpful on core aspects of preventive and developmental health care.

Information about resources for parents in the community: proportion of parents who had their informational needs met.

Information to address parental concerns: proportion of children whose parents had concerns about their child's learning, development and behavior and they received information to address their concerns.

Preventive and developmental health care for young children: average percentage of individual care components (assessed in the Promoting Healthy Development Survey [PHDS]) a child received.

Preventive and developmental health care for young children: proportion of children who received all individual care components measures in the Promoting Healthy Development Survey (PHDS).

Standardized developmental and behavioral screening: proportion of children whose health care provider administered a parent-completed standardized developmental and behavioral screening tool.

February 11, 2008

Institute for Clinical Systems Improvement

Heart failure in adults: percentage of adult heart failure patients to whom (or to their caregivers) written or verbal instructions or educational material are given during the clinic visit, addressing one or more of the following: activity level, diet, medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen (primary care and outpatient cardiology). This updates a previously published measure summary.

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and met the following (for which they are eligible) at their last clinic visit: prescribed or were taking ACEI/ARB, prescribed or were on beta blocker therapy, non-smoker (primary care and outpatient cardiology). This updates a previously published measure summary.

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were on beta-blocker therapy within the last 12 months of the clinic visit or who have a contraindication to taking beta-blockers (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were taking an ACEI or ARB within the last 12 months of the clinic visit, or who have contradictions to taking both ACEI or an ARB (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have not used tobacco anytime during the previous year (primary care and outpatient cardiology). This updates a previously published measure summary.

Heart failure in adults: percentage of adult heart failure patients who have used tobacco anytime during the previous year and who were given smoking cessation advice or counseling at the last clinic visit (primary care and outpatient cardiology). This updates a previously published measure summary.

Heart failure in adults: percentage of adult heart failure patients with documentation that LVS function was evaluated or will be evaluated (primary care and outpatient cardiology). This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her caregiver at discharge or during the hospital stay, addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge. This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have a contraindication to taking beta-blockers, who are prescribed beta-blocker therapy at hospital discharge. This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have contraindications to taking both ACEI and ARBs, who are prescribed an ACEI or an ARB at hospital discharge. This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have used tobacco anytime during the year prior to hospital arrival and who are given smoking cessation advice or counseling during the hospital stay or at discharge. This updates a previously published measure summary.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. This updates a previously published measure summary.

February 4, 2008

National Committee for Quality Assurance

Appropriate testing for children with pharyngitis: percentage of children 2 to 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. This updates a previously published measure summary.

Appropriate treatment for children with upper respiratory infection (URI): percentage of children 3 months to 18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription. This updates a previously published measure summary.

Asthma: percentage of members 5 to 56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. This updates a previously published measure summary.

Avoidance of antibiotic treatment in adults with acute bronchitis: percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. This updates a previously published measure summary.

Breast cancer screening: percentage of women 40 to 69 years of age who had one or more mammograms during the measurement year or the year prior to the measurement year. This updates a previously published measure summary.

Cervical cancer screening: percentage of women 21 to 64 years of age who received one or more Pap tests during the measurement year or the two years prior to the measurement year. This updates a previously published measure summary.

Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP), three injectible polio virus (IPV), one measles-mumps-rubella (MMR), three haemophilus influenza type B (HiB), three hepatitis B, one chicken pox vaccination (VZV) and four pneumococcal conjugate vaccinations by their second birthday (combination #3). This updates a previously published measure summary.

Childhood immunization status: percentage of enrolled children who had four diphtheria, tetanus, and acellular pertussis (DTaP/DT), three injectible polio virus (IPV), one measles-mumps-rubella (MMR), three haemophilus influenza type B (HiB), three hepatitis B and one chicken pox vaccination (VZV) by their second birthday (combination #2). This updates a previously published measure summary.

Chlamydia screening: percentage of women 16 to 25 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. This updates a previously published measure summary.

Chronic obstructive pulmonary disease (COPD): percentage of health plan members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. This updates a previously published measure summary.

Colorectal cancer screening: percentage of adults 50 to 80 years of age who had appropriate screening for colorectal cancer. This updates a previously published measure summary.

Glaucoma screening: percentage of Medicare members 65 years and older without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye-care professional for the early identification of glaucomatous conditions. This updates a previously published measure summary.

Lead screening in children: percentage of children two years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday.

Pharmacotherapy management of COPD exacerbation: percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to December 1 of the measurement year and who were dispensed a bronchodilator within 30 days of the event.

Pharmacotherapy management of COPD exacerbation: percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 to December 1 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event.

January 28, 2008

Centers for Medicare & Medicaid Services

Nursing facility chronic care: percent of eligible and willing long-stay residents given the influenza vaccination during the flu season.

Nursing facility chronic care: percent of eligible and willing long-stay residents who were assessed and given pneumococcal vaccination.

Nursing facility post acute care: percent of eligible and willing short-stay residents given the influenza vaccination during the flu season.

Nursing facility post acute care: percent of eligible and willing short-stay residents who were assessed and given pneumococcal vaccination.

Institute for Clinical Systems Improvement

Immunizations: percentage of adolescents who are on time with recommended immunizations (Hep B, Hep A, HPV, MMR, MCV4, Tdap, VZV). This updates a previously published measure summary.

Immunizations: percentage of two-year olds who are on time with their primary series of immunizations (DTaP, IPV, MMR, PCV7/PPV23, VZV, Hib, Hep B, Hep A, Rota). This updates a previously published measure summary.

Immunizations: percentage of young adults who are on time with Hepatitis B (Hep B). This updates a previously published measure summary.

Preventive services for adults: percentage of patients with all Level I preventive services on time according to the guideline delivery schedule. This updates a previously published measure summary.

Preventive services for children and adolescents: the percentage of patients who are on time with recommended immunizations. This updates a previously published measure summary.

Routine prenatal care: percentage of all identified preterm birth (PTB) modifiable risk factors assessed that receive an intervention. This updates a previously published measure summary.

Routine prenatal care: percentage of pregnant women who received counseling and education by the 28th week visit. This updates a previously published measure summary.

Routine prenatal care: percentage of vaginal birth after cesarean (VBAC) eligible women who receive general education describing risks and benefits of VBAC (e.g., the American College of Obstetricians and Gynecologists [ACOG] pamphlet on VBAC). This updates a previously published measure summary.

January 21, 2008

Physician Consortium for Performance Improvement®

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

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

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

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

State of Wisconsin, Department of Health and Family Services

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).

January 14, 2008

Australian Council on Healthcare Standards

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

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

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

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

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

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

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who die as a result of an adverse reaction, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who experience a cerebral hemorrhage, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient who experience abnormal bleeding, during the 6 month time period.

Monitoring of warfarin: percentage of non-same day separations receiving warfarin as an inpatient with an international normalized ratio (INR)/prothrombin reading greater than 5, during the 6 month time period.

Monitoring of warfarin: percentage of patients on hospital initiated warfarin who receive written drug information on discharge, during the 6 month time period.

Monitoring of warfarin: percentage of patients with an international normalized ratio (INR) result above the therapeutic range who have had their dosage reviewed prior to the next warfarin administration, during the 6 month time period.

January 7, 2008

Canadian Institute for Health Information

Hip fracture: risk adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges.

Physician to population ratio: total number of general physicians and family physicians per 100,000 population.

Physician to population ratio: total number of specialist physicians per 100,000 population.

Physician Consortium for Performance Improvement®

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

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

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

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

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