AMI: Acute Myocardial Infarction
AMI-2 pdf Aspirin prescribed at discharge
AMI-7A pdf Fibrinolytic therapy received within 30 minutes of hospital arrival
AMI-8A pdf Primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival
AMI-10 pdf Statin prescribed at discharge
OP-1 pdf Median time to fibrinolysis
OP-2 Fibrinolytic therapy received within 30 minutes of ED arrival
OP-3B Median time to transfer to another facility for acute coronary intervention
OP-4 Aspirin at arrival
OP-5 Median time to ECG
CAC: Children's Asthma Care
CAC-1 pdf Relievers for inpatient asthma
CAC-2 pdf Systemic corticosteroids for inpatient asthma
CAC-3 pdf Home management plan of care document given to patient/caregiver
ED: Emergency Department
ED-1B pdf Median time from ED arrival to ED departure for admitted ED patients
ED-2B pdf Admit decision time to ED departure time for admitted patients
OP-18b pdf Median time from ED arrival to ED departure for discharged ED patients
OP-20 Door to diagnostic evaluation by a qualified medical personnel
OP-22 Left without being seen
OP-21 pdf Median time to pain management for long bone fractures
OP-23 pdf Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan interpretation within 45 minutes of ED arrival
EDV pdf Emergency department volume
HAC: Hospital-Acquired Conditions
HAC-1 pdf Foreign object retained after surgery
HAC-2 Air embolism
HAC-3 Blood incompatibility
HAC-4 Pressure ulcer stages III & IV
HAC-5 Falls and trauma (includes fracture, dislocation, intracranial injury, crushing injury, burn, and electric shock)
HAC-6 Vascular catheter-associated infections
HAC-7 Catheter-associated urinary tract Infection
HAC-8 Manifestations of poor glycemic control (including diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, and secondary diabetes with hyperosmolarity)
HAI: Healthcare-Associated Infections
HAI-1-SIR pdf Central-line associated bloodstream infection (CLABSI)
HAI-2-SIR Catheter-associated urinary tract infection (CAUTI)
HAI-3-SIR Surgical site infections from colon surgery (SSI: Colon)
HAI-4-SIR Surgical site infections from abdominal hysterectomy (SSI: Hysterectomy)
HAI-5-SIR Methicillin-resistant Staphylococcus aureus (MRSA)
HAI-6-SIR Clostridium difficile (C-difficile)
HBIPS: Psychiatric
HBIPS-2a html Physical restraint - overall rate
HBIPS-2b Physical restraint - children (1 through 12 years)
HBIPS-2c Physical restraint - adolescent (13 through 17 years)
HBIPS-2d Physical restraint - adult (18 through 64 years)
HBIPS-2e Physical restraint - older adult (= 65 years)
HBIPS-3a html Seclusion - overall rate
HBIPS-3b Seclusion - children (1 through 12 years)
HBIPS-3c Seclusion - adolescent (13 through 17 years)
HBIPS-3d Seclusion - adult (18 through 64 years)
HBIPS-3e Seclusion - older adult (= 65 years)
HBIPS-4a html Multiple antipsychotic medications at discharge - overall rate
HBIPS-4b Multiple antipsychotic medications at discharge - children (1 through 12 years)
HBIPS-4c Multiple antipsychotic medications at discharge - adolescent (13 through 17 years)
HBIPS-4d Multiple antipsychotic medications at discharge - adult (18 through 64 years)
HBIPS-4e Multiple antipsychotic medications at discharge - older adult (= 65 years)
HBIPS-5a html Multiple antipsychotic medications at discharge with appropriate justification - overall rate
HBIPS-5b Multiple antipsychotic medications at discharge with appropriate justification - children (1 through 12 years)
HBIPS-5c Multiple antipsychotic medications at discharge with appropriate justification - adolescent (13 through 17 years)
HBIPS-5d Multiple antipsychotic medications at discharge with appropriate justification - adult (18 through 64 years)
HBIPS-5e Multiple antipsychotic medications at discharge with appropriate justification - older adult (= 65 years)
HBIPS-6a html Post discharge continuing care plan - overall rate
HBIPS-6b Post discharge continuing care plan - children (1 through 12 years)
HBIPS-6c Post discharge continuing care plan - adolescent (13 through 17 years)
HBIPS-6d Post discharge continuing care plan - adult (18 through 64 years)
HBIPS-6e Post discharge continuing care plan - older adult (= 65 years)
HBIPS-7a html Post discharge continuing care plan transmitted - overall rate
HBIPS-7b Post discharge continuing care plan transmitted - children (1 through 12 years)
HBIPS-7c Post discharge continuing care plan transmitted - adolescent (13 through 17 years)
HBIPS-7d Post discharge continuing care plan transmitted - adult (18 through 64 years)
HBIPS-7e Post discharge continuing care plan transmitted - older adult (= 65 years)
HCAHPS: Hospital Consumer Assessment of Health Plans Survey
H-CLEAN pdf Cleanliness of hospital environment (Individual measure)
H-COMP-1 Communication with nurses (summary measure)
H-COMP-2 Communication with doctors (summary measure)
H-COMP-3 Responsiveness of hospital staff (summary measure)
H-COMP-4 Pain management (summary measure)
H-COMP-5 Communication about medicines (summary measure)
H-COMP-6 Discharge information (summary measure)
H-QUIET Quietness of hospital environment (individual measure)
H-RATING Overall rating of hospital (global measure)
H-RECMND Willingness to recommend the hospital (global measure)
HF: Heart Failure
HF-1 pdf Discharge instructions
HF-2 pdf Evaluation of LVS function
HF-3 pdf ACEI or ARB for LVSD
IMM: Preventive Care
IMM-1A pdf Pneumococcal immunization
IMM-2 pdf Influenza immunization
IMM-3 pdf Healthcare workers given influenza vaccination
MRC: Mortality, Readmissions and Complications
COMP-THA/TKA pdf Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
MORT-30-AMI pdf Hospital 30-day, all-cause, RSMR following AMI hospitalization
MORT-30-HF pdf Hospital 30-day, all-cause, RSMR following HF hospitalization
MORT-30-PN pdf Hospital 30-day, all-cause, RSMR following pneumonia hospitalization
MORT-30-COPD pdf Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate
MORT-30-STK pdf Acute Ischemic Stroke (STK) 30-Day Mortality Rate
READM-30-AMI pdf Hospital, 30-day all-cause RSRR following AMI hospitalization
READM-30-HF pdf Hospital 30-day all-cause, RSRR following HF hospitalization
READM-30-HWR pdf Hospital-wide all-cause unplanned readmission (HWR) measure
READM-30-PCI html Hospital 30-day risk-standardized readmission rate following percutaneous coronary intervention
READM-30-PN pdf Hospital 30-day all-cause, RSRR following pneumonia hospitalization
READM-30-THA/TKA pdf Hospital-level 30 -day all -cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
READM-30-COPD pdf Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate
READM-30-STK pdf Stroke (STK) 30-Day Readmission Rate
MV: Medicare Volume
MPM-038 html Extracranial procedures w CC
MPM-039 Extracranial procedures w/o CC/MCC
MPM-190 html Chronic obstructive pulmonary disease w MCC
MPM-191 Chronic obstructive pulmonary disease w CC
MPM-192 Chronic obstructive pulmonary disease w/o CC/MCC
MPM-193 html Simple pneumonia and pleurisy w MCC
MPM-219 html Cardiac valve and other major cardiothoracic procedures w/o cardiac catheterization w MCC
MPM-220 Cardiac valve and other major cardiothoracic procedures w/o cardiac catheterization w CC
MPM-221 Cardiac valve and other major cardiothoracic procedures w/o cardiac catheterization w/o CC/MCC
MPM-224 html Cardiac defibrillator implant w cardiac catheterization w/o AMI/HF/shock w MCC
MPM-225 Cardiac defibrillator implant w cardiac catheterization w/o AMI/HF/shock w/o MCC
MPM-226 Cardiac defibrillator implant w/o cardiac catheterization w MCC
MPM-227 Cardiac defibrillator implant w/o cardiac catheterization w/o MCC
MPM-235 html Coronary bypass w/o cardiac catheterization w MCC
MPM-236 Coronary bypass w/o cardiac catheterization w/o MCC
MPM-237 html Major cardiovascular procedures w MCC
MPM-243 html Permanent cardiac pacemaker implant w CC
MPM-244 Permanent cardiac pacemaker implant w/o CC/MCC
MPM-247 html Percutaneous cardiovascular procedures w drug-eluting stent w/o MCC
MPM-280 html Acute myocardial infarction, discharged alive w MCC
MPM-281 Acute myocardial infarction, discharged alive w CC
MPM-282 Acute myocardial infarction, discharged alive w/o CC/MCC
MPM-291 html Heart failure and shock w MCC
MPM-292 Heart failure and shock w CC
MPM-293 Heart failure and shock w/o CC/MCC
MPM-313 html Chest Pain
MPM-328 html Stomach, esophageal & duodenal procedures w/o CC/MCC
MPM-329 html Major small and large bowel procedures w MCC
MPM-330 Major small and large bowel procedures w CC
MPM-331 Major small and large bowel procedures w/o CC/MCC
MPM-353 html Hernia procedures except inguinal and femoral w MCC
MPM-354 Hernia procedures except inguinal and femoral w CC
MPM-355 Hernia procedures except inguinal and femoral w/o CC/MCC
MPM-414 html Cholecystectomy except by laparoscope w/o c.d.e. w MCC
MPM-417 Laparoscopic cholecystectomy w/o c.d.e. w MCC
MPM-418 Laparoscopic cholecystectomy w/o c.d.e. w CC
MPM-419 Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC
MPM-459 html Spinal fusion except cervical w MCC
MPM-460 Spinal fusion except cervical w/o MCC
MPM-461 html Bilateral or multiple major joint procedures of lower extremity w MCC
MPM-462 Bilateral or multiple major joint procedures of lower extremity w/o MCC
MPM-466 html Revision of hip or knee replacement w MCC
MPM-467 Revision of hip or knee replacement w CC
MPM-468 Revision of hip or knee replacement w/o CC/MCC
MPM-469 html Major joint replacement or reattachment of lower extremity w MCC
MPM-470 Major joint replacement or reattachment of lower extremity w/o MCC
MPM-471 html Cervical spinal fusion w MCC
MPM-472 Cervical spinal fusion w CC
MPM-473 Cervical spinal fusion w/o CC/MCC
MPM-477 html Biopsies of musculoskeletal system and connective tissue w MCC
MPM-478 Biopsies of musculoskeletal system and connective tissue w CC
MPM-479 Biopsies of musculoskeletal system and connective tissue w/o CC/MCC
MPM-490 html Back & neck procedures except spinal fusion w CC/MCC or disc devices/neurostimulators
MPM-491 Back and neck procedures except spinal fusion w/o CC/MCC
MPM-507 html Major shoulder or elbow joint procedures w CC/MCC
MPM-508 Major shoulder or elbow joint procedures w/o CC/MCC
MPM-515 html Other musculoskelet system and connective tissue O.R. procedures w MCC
MPM-637 html Diabetes w MCC
MPM-656 html Kidney and ureter procedures for neoplasm w MCC
MPM-657 Kidney and ureter procedures for neoplasm w CC
MPM-658 Kidney and ureter procedures for neoplasm w/o CC/MCC
MPM-659 Kidney and ureter procedures for non-neoplasm w MCC
MPM-668 html Transurethral procedures w MCC
MPM-673 html Other kidney and urinary tract procedures w MCC
MPM-674 Other kidney and urinary tract procedures w CC
MPM-675 Other kidney and urinary tract procedures w/o CC/MCC
MPM-713 html Transurethral prostatectomy w CC/MCC
MPM-714 Transurethral prostatectomy w/o CC/MCC
MPM-743 html Uterine and adnexa procedures for non-malignancy w/o CC/MCC
MPM-748 html Female reproductive system reconstructive procedures
OIE: Outpatient Imaging Efficiency
OP-8 pdf MRI lumbar spine for low back pain
OP-9 pdf Mammography follow-up rates
OP-10 pdf Abdomen CT use of contrast material
OP-11 pdf Thorax CT use of contrast material
OP-13 pdf Cardiac imaging for preoperative risk assessment for non-cardiac low-risk surgery
OP-14 pdf Simultaneous use of brain CT and sinus CT
PC: Pregnancy and Delivery
PC-01 html Elective delivery
PCH: PPS-Exempt Cancer
PCH-1 pdf Adjuvant Chemotherapy for Stage III Colon Cancer
PCH-2 Combination Chemotherapy for AJCC T1c or Stage II or III Hormone Receptor-Negative Breast Cancer
PN: Pneumonia
PN-3B pdf Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
PN-6 pdf Initial antibiotic selection for CAP in immunocompetent patients
PSM: Patient Safety Measure
IQI-11 pdf Abdominal aortic aneurysm (AAA) repair mortality rate
IQI-19 pdf Hip fracture mortality rate
IQI-91 pdf Mortality for selected conditions
PSI-04 pdf Death rate among surgical inpatients with serious treatable complications
PSI-06 pdf Iatrogenic pneumothorax rate
PSI-11 pdf Postoperative respiratory failure rate
PSI-12 pdf Perioperative pulmonary embolism or deep vein thrombosis rate
PSI-14 pdf Postoperative wound dehiscence rate
PSI-15 pdf Accidental puncture or laceration rate
PSI-90 pdf Patient safety for selected indicators
PV: Procedures Volume
OP-26-CV pdf Cardiovascular
OP-26-E Eye
OP-26-GI Gastrointestinal
OP-26-GU Genitourinary
OP-26-MS Muscularskeletal
OP-26-N Nervous
OP-26-S Skin
SCIP: Surgical Care Improvement Project
OP-6 pdf Timing of antibiotic prophylaxis
OP-7 Prophylactic antibiotic selection for surgical patients
SCIP-CARD-2 pdf Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period
SCIP-INF-1 pdf Prophylactic antibiotic received within one hour prior to surgical incision
SCIP-INF-2 pdf Prophylactic antibiotic selection for surgical patients (Full)
SCIP-INF-3 pdf Prophylactic antibiotics discontinued within 24 hours after surgery end time
SCIP-INF-4 pdf Cardiac surgery patients with controlled postoperative blood glucose
SCIP-INF-9 pdf Urinary catheter removed on postoperative day 1 (POD 1) or postoperative day 2 (POD 2) with day of surgery being day zero
SCIP-INF-10 pdf Surgery patients with perioperative temperature management
SCIP-VTE-1 pdf Surgery patients with recommended venous thromboembolism prophylaxis ordered
SCIP-VTE-2 pdf Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery
SM: Structural Measure
OP-12 pdf The ability for providers with HIT to receive laboratory data electronically directly into their qualified/certified EHR system as discrete searchable data
OP-17 pdf Tracking clinical results between visits
OP-25 pdf Safe surgery checklist use
SM-PART-
GEN-SURG
pdf Participation in a systematic database registry for general surgery
SM-PART-CARD Participation in a systematic database for cardiac surgery
SM-PART-NURSE Participation in a systematic database for nursing sensitive care
SM-PART-STROKE Participation in a systematic database for stroke care
ACS-REGISTRY html Acute coronary syndrome registry
SPP: Medicare Spending
MSPB-1 pdf Medicare spending per beneficiary
SPP-AFT 1 through 30 days After Discharge from Index Hospital
SPP-DUR During Index Hospital Admission
SPP-PRI 1 to 3 days Prior to Index Hospital Admission
PAYM-30-AMI pdf Hospital-level, risk-standardized payment associated with a 30-day episode of care for Acute Myocardial Infarction (AMI)
STK: Stroke
STK-1 pdf Venous thromboembolism prophylaxis
STK-2 pdf Discharged on antithrombotic therapy
STK-3 pdf Anticoagulation therapy for atrial fibrillation/flutter
STK-4 pdf Thrombolytic therapy
STK-5 pdf Antithrombotic therapy by end of hospital day 2
STK-6 pdf Discharged on statin medication
STK-8 pdf Stroke education
STK-10 pdf Assessed for rehabilitation
VTE: Blood Clot Prevention
VTE-1 pdf Venous thromboembolism prophylaxis
VTE-2 pdf Intensive care unit venous thromboembolism prophylaxis
VTE-3 pdf Venous thromboembolism patients with anticoagulation overlap therapy
VTE-4 pdf Venous thromboembolism patients receiving unfractioned herapin with dosages/platelet count monitoring by protocol or nomogram
VTE-5 pdf Venous thromboembolism warfarin therapy discharge instructions
VTE-6 pdf Hospital acquired potentially-preventable venous thromboembolism