172
33
SCIP-Inf-7 Colorectal surgery patients with immediate postoperative normothermia
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Colorectal surgery patients with immediate normothermia within the first hour after leaving the operating room.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
172
33
SCIP-Inf-7 Colorectal surgery patients with immediate postoperative normothermia
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Surgery patients whose first recorded temperature was within the range of 96.8-100.4F within the first hour after leaving the operating room.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
172
33
SCIP-Inf-7 Colorectal surgery patients with immediate postoperative normothermia
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected colorectal surgery patients with no evidence of prior infection. Excludes patients who are less than 18 years of age; patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases; burn patients; patients with documented infection prior to surgical procedure; patients who expired intraoperatively.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
172
33
SCIP-Inf-7 Colorectal surgery patients with immediate postoperative normothermia
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
172
33
SCIP-Inf-7 Colorectal surgery patients with immediate postoperative normothermia
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
171
32
SCIP-Inf-6 Surgery patients with appropriate hair removal
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgery patients with appropriate surgical site hair removal.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
171
32
SCIP-Inf-6 Surgery patients with appropriate hair removal
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Surgery patients with surgical site hair removal with clippers or dipilatory or with no surgical site hair removal.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
171
32
SCIP-Inf-6 Surgery patients with appropriate hair removal
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgery patients. Excludes patients less than 18 years of age; patients who performed their own hair removal; patients whose methods of hair removal could not be determined.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
171
32
SCIP-Inf-6 Surgery patients with appropriate hair removal
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
171
32
SCIP-Inf-6 Surgery patients with appropriate hair removal
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
170
31
SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Cardiac surgery patients with controlled 6 AM serum glucose (<= 200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with surgery end date being postoperative day zero (POD 0).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
170
31
SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Surgery patients with controlled 6 AM serum glucose on POD 1 and POD 2.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
170
31
SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Cardiac surgery patients with no evidence of prior infection. Excludes patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases; patients less than 18 years of age; patients with documented infection prior to surgical procedure; burn or transplant patients.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
170
31
SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
170
31
SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
169
15
PN-6b Antibiotic selection for CAP in immunocompetent non-ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Immunocompetent non-ICU patients with CAP who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
169
15
PN-6b Antibiotic selection for CAP in immunocompetent non-ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of pneumonia patients who received antibiotics consistent with current guidelines during the first 24 hours of their hospitalization.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
169
15
PN-6b Antibiotic selection for CAP in immunocompetent non-ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Discharges 18 years of age and older with a principal diagnosis code of pneumonia, septicemia, or respiratory failure. Excludes patients received in transfer from another acute care or critical access hospital; patients who have no working diagnosis of pneumonia at time of admission; patients receiving comfort measures only; patients who do not receive antibiotics during hospitalization or within 36 hours after arrival; patients who are compromised; patients involved in protocols or clinical trials; patients with Healthcare Associated PN; patients who had no chest x-ray or CT scan that indicated positive infiltrate within 24 hours prior to arrival or anytime during hospitalization; patients in the ICU.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
169
15
PN-6b Antibiotic selection for CAP in immunocompetent non-ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
169
15
PN-6b Antibiotic selection for CAP in immunocompetent non-ICU patient
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
168
15
PN-6a Antibiotic selection for CAP in immunocompetent ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Immunocompetent ICU patients with CAP who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
168
15
PN-6a Antibiotic selection for CAP in immunocompetent ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of pneumonia patients who received antibiotics consistent with current guidelines during the first 24 hours of their hospitalization.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
168
15
PN-6a Antibiotic selection for CAP in immunocompetent ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Discharges 18 years of age and older with a principal diagnosis code of pneumonia, septicemia, or respiratory failure. Excludes patients received in transfer from another acute care or critical access hospital; patients who have no working diagnosis of pneumonia at time of admission; patients receiving comfort measures only; patients who do not receive antibiotics during hospitalization or within 36 hours after arrival; patients who are compromised; patients involved in protocols or clinical trials; patients with Healthcare Associated PN; patients who had no chest x-ray or CT scan that indicated positive infiltrate within 24 hours prior to arrival or anytime during hospitalization; patients not in the ICU.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
168
15
PN-6a Antibiotic selection for CAP in immunocompetent ICU patient
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
168
15
PN-6a Antibiotic selection for CAP in immunocompetent ICU patient
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
167
30
CMS Appropriate Care Measure (21 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 21 hospital quality measures that shows the percentage of patients who received the recommended care for all of the measures in this set that they were eligible to receive. The bundle rate is calculated by dividing the number of patients considered compliant (measure category assignment of E for every eligible measure) by the total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
167
30
CMS Appropriate Care Measure (21 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Patients that received the appropriate care (measure category assignment of E) for each measure in the set that they were eligible to receive. These patients are considered compliant.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
167
30
CMS Appropriate Care Measure (21 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Patients that were eligible (measure category assignment of D or E) for at least one of the following 21 measures: AMI-1 Aspirin at Arrival; AMI-2 Aspirin Prescribed at Discharge; AMI-3 ACEI or ARB for LVSD; AMI-4 Adult Smoking Cessation; AMI-5 Beta Blocker Prescribed at Discharge; AMI-6 Beta Blocker at Arrival; AMI-7a Fibrinolytic Therapy Received Within 30 Min. of Arrival; AMI-8a PCI Received Within 90 Min. of Arrival; HF-1 Discharge Instructions; HF-2 Evaluation of LVS Function; HF-3 ACEI or ARB for LVSD; HF-4 Adult Smoking Cessation; PN-1 Oxygenation Assessment; PN-2 Pneumococcal Vaccination; PN-3b Blood Cultures in the ED Prior to Antibiotic; PN-4 Adult Smoking Cessation; PN-5b Initial Antibiotic Received Within 4 Hours of Hospital Arrival; PN-6 Antibiotic Selection for CAP in Immunocompetent Patient (PN-6 is a combination of PN-6a and PN-6b); PN-7 Influenza Vaccination; SCIP-Inf-1 Antibiotic Received One Hour Prior to Surgical Incision; SCIP-Inf-3 Antibiotics Discontinued Within 24/48 Hours After Surgery End.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
167
30
CMS Appropriate Care Measure (21 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
167
30
CMS Appropriate Care Measure (21 Metric)
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
162
30
CMS Appropriate Care Measure (10 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 10 hospital quality measures that shows the percentage of patients who received the recommended care for all of the measures in this set that they were eligible to receive. The bundle rate is calculated by dividing the number of patients considered compliant (measure category assignment of E for every eligible measure) by the total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
162
30
CMS Appropriate Care Measure (10 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Patients that received the appropriate care (measure category assignment of E) for each measure in the set that they were eligible to receive. These patients are considered compliant.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
162
30
CMS Appropriate Care Measure (10 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Patients that were eligible (measure category assignment of D or E) for at least one of the following 10 measures: AMI-1 Aspirin at Arrival; AMI-2 Aspirin Prescribed at Discharge; AMI-3 ACEI or ARB for LVSD; AMI-5 Beta Blocker Prescribed at Discharge; AMI-6 Beta Blocker at Arrival; HF-2 LVF Assessment; HF-3 ACEI or ARB for LVSD; PN-1 Oxygenation Assessment; PN-2 Pneumococcal Vaccination; PN-5b Initial Antibiotic Received Within 4 Hours of Hospital Arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
162
30
CMS Appropriate Care Measure (10 Metric)
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
162
30
CMS Appropriate Care Measure (10 Metric)
0
UHC FAQ Center
http://www.uhc.edu/faq/faq.asp
161
15
Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
161
15
Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia ICU patients 18 year of age and older. Exclude patients received in transfer from another acute care or critical care access hospital, including another emergency department; patients who have no working diagnosis of pneumonia at the time of admission; patients receiving comfort measures only; patients having no blood cultures obtained; patients not transferred or admitted to the ICU within 24 hours of hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
161
15
Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival who had blood cultures performed within 24 hours prior to or 24 hours after arrival at the hospital.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
161
15
Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Target:
90% compliance rate
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
161
15
Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
24
13
Acute Myocardial Infarction - Aspirin at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
24
13
Acute Myocardial Infarction - Aspirin at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients who received aspirin within 24 hours before or after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
24
13
Acute Myocardial Infarction - Aspirin at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients without aspirin contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital on day of arrival; patients received in transfer from another hospital, including another emergency department; patients discharged on day of or day after arrival; patients who expired on day of arrival; patients who left against medical advice on day of arrival; patients with one or more aspirin contraindications.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
24
13
Acute Myocardial Infarction - Aspirin at arrival
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
25
13
Acute Myocardial Infarction - Aspirin prescribed at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
25
13
Acute Myocardial Infarction - Aspirin prescribed at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients who are prescribed aspirin at hospital discharge
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
25
13
Acute Myocardial Infarction - Aspirin prescribed at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients without aspirin contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with one or more aspirin contraindications.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
25
13
Acute Myocardial Infarction - Aspirin prescribed at discharge
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
26
13
Acute Myocardial Infarction - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
26
13
Acute Myocardial Infarction - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients with LVSD who are prescribed an ACEI or ARB at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
26
13
Acute Myocardial Infarction - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients with LVSD and without ACEI and ARB contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with chart documentation of participation in a clinical trial.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
26
13
Acute Myocardial Infarction - ACEI or ARB for LVSD
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
27
13
Acute Myocardial Infarction - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
27
13
Acute Myocardial Infarction - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
27
13
Acute Myocardial Infarction - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients with a history of smoking cigarettes anytime during the year prior to hospital arrival. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
27
13
Acute Myocardial Infarction - Adult smoking cessation
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
28
13
Acute Myocardial Infarction - Beta blocker Rx at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
28
13
Acute Myocardial Infarction - Beta blocker Rx at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients who are prescribed a beta blocker at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
28
13
Acute Myocardial Infarction - Beta blocker Rx at discharge
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients without beta blocker contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with one or more of the following beta blocker contraindications/reasons for not prescribing beta blocker documented in the medical record, please see exclusion population in AMI 5-2.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
28
13
Acute Myocardial Infarction - Beta blocker Rx at discharge
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
29
13
Acute Myocardial Infarction - Beta blocker at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
29
13
Acute Myocardial Infarction - Beta blocker at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients who received a beta blocker within 24 hours after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
29
13
Acute Myocardial Infarction - Beta blocker at arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients without beta blocker contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients received in transfer from another acute care hospital on day of arrival, including another emergency department; patients discharged on day of arrival; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with one or more of the following beta blocker contraindications/reasons for not prescribing beta blocker documented in the medical record, please see excluded population page for AMI 6-2.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
29
13
Acute Myocardial Infarction - Beta blocker at arrival
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
30
13
AMI-7a Fibrinolytic therapy received within 30 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
30
13
AMI-7a Fibrinolytic therapy received within 30 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients whose time from hospital arrival to fibrinolysis is 30 minutes or less.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
30
13
AMI-7a Fibrinolytic therapy received within 30 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients with ST elevation or LBBB on ECG who received fibrinolytic therapy. Exclude patients less than 18 years of age; patients received in transfer from another acute care hospital, including another emergency department; patients with comfort measures only; patients who did not receive fibrinolytic therapy within 30 minutes and had a documented reason for delay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
30
13
AMI-7a Fibrinolytic therapy received within 30 mins of arrival
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
30
13
AMI-7a Fibrinolytic therapy received within 30 mins of arrival
1
Target:
90% compliance rate
31
13
AMI-8a PCI received within 90 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
31
13
AMI-8a PCI received within 90 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
AMI patients whose time from hospital arrival to PCI is 90 minutes or less.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
31
13
AMI-8a PCI received within 90 mins of arrival
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients with ST elevation or LBBB on ECG who received PCI within 24 hours after hospital arrival. Exclude patients less than 18 years of age; patients received in transfer from another acute care hospital, including another emergency department; patients with comfort measures only; patients administered fibrinolytic therapy; PCI described as non-primary; patients who did not receive PCI within 90 minutes and had a documented reason for delay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
31
13
AMI-8a PCI received within 90 mins of arrival
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Acute myocardial infarction (AMI) patients who expired during hospital stay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Inpatient mortality of AMI patients.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
AMI patients. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients received in transfer from another acute care hospital; patients discharged to hospice; patient deaths in the emergency department.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
1
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
34
14
Heart Failure - Discharge instructions
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Heart failure patients discharged home with written instructions or educational material given to a patient or care giver 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 is symptoms worsen.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
34
14
Heart Failure - Discharge instructions
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
34
14
Heart Failure - Discharge instructions
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Heart failure patients discharged home. Excludes patients less than 18 years of age; patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during the hospitalization.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
34
14
Heart Failure - Discharge instructions
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
35
14
Heart Failure - LVF assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
35
14
Heart Failure - LVF assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Heart failure patients with documentation in the hospital record that LVF was assessed before arrival, during hospitalization, or is planned for after discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
35
14
Heart Failure - LVF assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Heart failure patients. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with documented reasons for no LVS function evaluation; patients who had a left ventricular assistive device (LVAD) heart transplant procedure during the hospitalization.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
35
14
Heart Failure - LVF assessment
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
36
14
Heart Failure - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Heart failure patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge. For the purposes of this measure, LVSD is defined as chart documentation of a lft ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
36
14
Heart Failure - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Heart failure patients who are prescribed an ACEI or ARB at hospital discharge.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
36
14
Heart Failure - ACEI or ARB for LVSD
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Heart failure patients with LVSD and without ACEI and ARB contraindications. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients with chart documentation of participation in a clinical trial.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
36
14
Heart Failure - ACEI or ARB for LVSD
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
37
14
Heart Failure - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Heart failure patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
37
14
Heart Failure - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Heart failure patients who receive smoking cessation advice or counseling during the hospital stay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
37
14
Heart Failure - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Heart failure patients with a history of smoking cigarettes anytime during the year prior to hospital arrival. Exclude patients less than 18 years of age; patients transferred to another acute care hospital; patients who expired; patients who left against medical advice; patients discharged to hospice; patients who had a LVAD or heart transplant procedure during the hospitalization.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
37
14
Heart Failure - Adult smoking cessation
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
40
15
Pneumonia - Oxygenation assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
40
15
Pneumonia - Oxygenation assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of pneumonia patients whose arterial oxygenation was assessed by arterial blood gas (ABG) or pulse oximetry within 24 hours prior to or after hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
40
15
Pneumonia - Oxygenation assessment
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 18 years of age and older. Exclude patients received in transfer from another acute care or critical care access hospital, including another emergency department; patients who have no working diagnosis of pneumonia at the time of admission; patients receiving comfort measures only; patients less than 18 years of age.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
40
15
Pneumonia - Oxygenation assessment
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
41
15
Pneumonia - Pneumococcal screening / vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
41
15
Pneumonia - Pneumococcal screening / vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
41
15
Pneumonia - Pneumococcal screening / vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 65 years of age and older. Exclude patients received in transfer from another acute care or critical care access hospital, including another emergency department; patients who have no working diagnosis of pneumonia at the time of admission; patients who were discharged to a federal hospital; patients who were transferred to another short-term general hospital; patients who left against medical advice; patients receiving comfort measures only; patients who expired; patients discharged to hospice.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
41
15
Pneumonia - Pneumococcal screening / vaccination
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
43
15
Pneumonia - Blood culture prior to antibiotics
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
43
15
Pneumonia - Blood culture prior to antibiotics
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
43
15
Pneumonia - Blood culture prior to antibiotics
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 18 years of age and older who have an initial blood culture collected in the emergency department. Exclude patients received in transfer from another acute care or critical care access hospital, including another emergency department; patients who had no working diagnosis of pneumonia at the time of admission; patients receiving comfort measures only; patients who did not receive antibiotics or a blood culture.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
43
15
Pneumonia - Blood culture prior to antibiotics
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
44
15
Pneumonia - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
44
15
Pneumonia - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Adult PN patients who receive smoking cessation advice or counseling during the hospital stay.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
44
15
Pneumonia - Adult smoking cessation
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 18 years of age and older with a history of smoking cigarettes anytime during the year prior to hospital arrival. Exclude patients transferred to another acute care hospital; patients received in transfer from another hospital's emergency department; patients who left against medical advice; patients transferred to a federal hospital; patients discharged to hospice; patients who expired; patients who have no working diagnosis of pneumonia at the time of admission; patients receiving Comfort Measures Only; patients less than 18 years of age.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
44
15
Pneumonia - Adult smoking cessation
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
47
15
Pneumonia - Time to first dose of antibiotic <= 4 hours
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
47
15
Pneumonia - Time to first dose of antibiotic <= 4 hours
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of patients who received their first antibiotic dose within 4 hours from hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
47
15
Pneumonia - Time to first dose of antibiotic <= 4 hours
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 18 years of age and older. Exclude patients received in transfer from another hospital's emergency department; patients who had no working diagnosis of pneumonia at the time of admission; patients who do not receive antibiotics during hospitalization; patients who received comfort measures only; patients whose initial antibiotic was administered more than 36 hours from the time of arrival; patients who have received antibiotics within 24 hours prior to hospital arrival.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
47
15
Pneumonia - Time to first dose of antibiotic <= 4 hours
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
61
21
Pregnancy Related - VBAC
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Prenatal patient evaluation, management, and treatment selection concerning vaginal deliveries in patients who have a history of previous cesarean section and an exclusion of abortion as identified in Appendix A, Table 4.06.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
61
21
Pregnancy Related - VBAC
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Patients with vaginal birth after cesarean section (VBAC).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
61
21
Pregnancy Related - VBAC
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All patients who delivered with a history of previous cesarean section.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
61
21
Pregnancy Related - VBAC
1
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
61
21
Pregnancy Related - VBAC
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
60
21
Pregnancy Related - Inpatient mortality neonates
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Live-born neonates who expire before the neonate becomes age 28 days.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
60
21
Pregnancy Related - Inpatient mortality neonates
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
All neonates who expire at the facility before the neonate becomes age 28 days.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
60
21
Pregnancy Related - Inpatient mortality neonates
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All live-born neonates. Includes transfers in from another acute care hospital. Excludes patients transferred to another acute care hospital.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
60
21
Pregnancy Related - Inpatient mortality neonates
1
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
60
21
Pregnancy Related - Inpatient mortality neonates
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Patients who have vaginal deliveries with third or fourth degree perineal laceration.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
All patients with third or fourth degree perineal laceration.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All patients with vaginal deliveries.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
1
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
116
23
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a flouroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
116
23
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
116
23
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
116
23
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
117
24
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
117
24
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
117
24
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
117
24
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
118
25
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
118
25
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
118
25
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
118
25
0
Specifications Manual for National Hospital Quality Measures, version 2.0
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
23
13
Acute Myocardial Infarction - AMI - Mortality
1
Target:
HQA expected mortality (O/E ratio of 1.0)
24
13
Acute Myocardial Infarction - Aspirin at arrival
1
Target:
90% compliance rate
25
13
Acute Myocardial Infarction - Aspirin prescribed at discharge
1
Target:
90% compliance rate
26
13
Acute Myocardial Infarction - ACEI or ARB for LVSD
1
Target:
90% compliance rate
27
13
Acute Myocardial Infarction - Adult Smoking Cessation
1
Target:
90% compliance rate
29
13
Acute Myocardial Infarction - Beta blocker at arrival
1
Target:
90% compliance rate
28
13
Acute Myocardial Infarction - Beta blocker Rx at discharge
1
Target:
90% compliance rate
31
13
Acute Myocardial Infarction - Time to PTCA <= 120 mins
1
Target:
90% compliance rate
34
14
Heart Failure - Discharge instructions
1
Target:
90% compliance rate
35
14
Heart Failure - LVF assessment
1
Target:
90% compliance rate
36
14
Heart Failure - ACEI or ARB for LVSD
1
Target:
90% compliance rate
37
14
Heart Failure - Adult smoking cessation
1
Target:
90% compliance rate
40
15
Pneumonia - Oxygenation assessment
1
Target:
90% compliance rate
41
15
Pneumonia - Pneumococcal screening / vaccination
1
Target:
90% compliance rate
43
15
Pneumonia - Blood culture prior to antibiotics
1
Target:
90% compliance rate
44
15
Pneumonia - Adult smoking cessation
1
Target:
90% compliance rate
45
15
Pneumonia - Pediatric smoking cessation
1
Target:
90% compliance rate
47
15
Pneumonia - Time to first dose of antibiotic <= 4 hours
1
Target:
90% compliance rate
60
21
Pregnancy Related - Inpatient Mortality Neonates
1
Target:
HQA expected mortality (O/E ratio of 1.0)
61
21
Pregnancy Related - VBAC uncomplicated
1
Target:
None
62
21
Pregnancy Related - 3rd or 4th degree perineal laceration
1
Target:
HQA expected rate (O/E ratio of 1.0)
116
23
Surgical Infection Prevention - Antibiotic received 1 hour prior
1
Target:
90% compliance rate
117
24
Surgical Infection Prevention - Antibiotic Selection
1
Target:
90% compliance rate
118
25
Surgical Infection Prevention - Antibiotic Discontinued Within 24/48 Hours
1
Target:
90% compliance rate
125
23
SCIP - Antibiotic Received One Hour Prior - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
125
23
SCIP - Antibiotic Received One Hour Prior - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
125
23
SCIP - Antibiotic Received One Hour Prior - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
125
23
SCIP - Antibiotic Received One Hour Prior - CABG
1
Target:
90% compliance rate
125
23
SCIP - Antibiotic Received One Hour Prior - CABG
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
126
23
SCIP - Antibiotic Received One Hour Prior - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
126
23
SCIP - Antibiotic Received One Hour Prior - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
126
23
SCIP - Antibiotic Received One Hour Prior - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
126
23
SCIP - Antibiotic Received One Hour Prior - Cardiac surgery
1
Target:
90% compliance rate
126
23
SCIP - Antibiotic Received One Hour Prior - Cardiac surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
127
23
SCIP - Antibiotic Received One Hour Prior - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
127
23
SCIP - Antibiotic Received One Hour Prior - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
127
23
SCIP - Antibiotic Received One Hour Prior - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
127
23
SCIP - Antibiotic Received One Hour Prior - Hip arthroplasty
1
Target:
90% compliance rate
127
23
SCIP - Antibiotic Received One Hour Prior - Hip arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
128
23
SCIP - Antibiotic Received One Hour Prior - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
128
23
SCIP - Antibiotic Received One Hour Prior - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
128
23
SCIP - Antibiotic Received One Hour Prior - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
128
23
SCIP - Antibiotic Received One Hour Prior - Knee arthroplasty
1
Target:
90% compliance rate
128
23
SCIP - Antibiotic Received One Hour Prior - Knee arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
129
23
SCIP - Antibiotic Received One Hour Prior - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
129
23
SCIP - Antibiotic Received One Hour Prior - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
129
23
SCIP - Antibiotic Received One Hour Prior - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
129
23
SCIP - Antibiotic Received One Hour Prior - Colon surgery
1
Target:
90% compliance rate
129
23
SCIP - Antibiotic Received One Hour Prior - Colon surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
130
23
SCIP - Antibiotic Received One Hour Prior - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
130
23
SCIP - Antibiotic Received One Hour Prior - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
130
23
SCIP - Antibiotic Received One Hour Prior - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
130
23
SCIP - Antibiotic Received One Hour Prior - Hysterectomy
1
Target:
90% compliance rate
130
23
SCIP - Antibiotic Received One Hour Prior - Hysterectomy
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
131
23
SCIP - Antibiotic Received One Hour Prior - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
131
23
SCIP - Antibiotic Received One Hour Prior - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
131
23
SCIP - Antibiotic Received One Hour Prior - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of selected surgical patients who received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
131
23
SCIP - Antibiotic Received One Hour Prior - Vascular surgery
1
Target:
90% compliance rate
131
23
SCIP - Antibiotic Received One Hour Prior - Vascular surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
132
24
SCIP - Antibiotic Selection - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
132
24
SCIP - Antibiotic Selection - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
132
24
SCIP - Antibiotic Selection - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
132
24
SCIP - Antibiotic Selection - CABG
1
Target:
90% compliance rate
132
24
SCIP - Antibiotic Selection - CABG
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
133
24
SCIP - Antibiotic Selection - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
133
24
SCIP - Antibiotic Selection - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
133
24
SCIP - Antibiotic Selection - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
133
24
SCIP - Antibiotic Selection - Cardiac surgery
1
Target:
90% compliance rate
133
24
SCIP - Antibiotic Selection - Cardiac surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
134
24
SCIP - Antibiotic Selection - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
134
24
SCIP - Antibiotic Selection - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
134
24
SCIP - Antibiotic Selection - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
134
24
SCIP - Antibiotic Selection - Hip arthroplasty
1
Target:
90% compliance rate
134
24
SCIP - Antibiotic Selection - Hip arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
135
24
SCIP - Antibiotic Selection - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
135
24
SCIP - Antibiotic Selection - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
135
24
SCIP - Antibiotic Selection - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
135
24
SCIP - Antibiotic Selection - Knee arthroplasty
1
Target:
90% compliance rate
135
24
SCIP - Antibiotic Selection - Knee arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
136
24
SCIP - Antibiotic Selection - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
136
24
SCIP - Antibiotic Selection - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
136
24
SCIP - Antibiotic Selection - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
136
24
SCIP - Antibiotic Selection - Colon surgery
1
Target:
90% compliance rate
136
24
SCIP - Antibiotic Selection - Colon surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
137
24
SCIP - Antibiotic Selection - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
137
24
SCIP - Antibiotic Selection - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
137
24
SCIP - Antibiotic Selection - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
137
24
SCIP - Antibiotic Selection - Hysterectomy
1
Target:
90% compliance rate
137
24
SCIP - Antibiotic Selection - Hysterectomy
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
138
24
SCIP - Antibiotic Selection - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
138
24
SCIP - Antibiotic Selection - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
138
24
SCIP - Antibiotic Selection - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
138
24
SCIP - Antibiotic Selection - Vascular surgery
1
Target:
90% compliance rate
138
24
SCIP - Antibiotic Selection - Vascular surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
139
25
SCIP - Antibiotics Discontinued Within 24 Hours - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
139
25
SCIP - Antibiotics Discontinued Within 24 Hours - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
139
25
SCIP - Antibiotics Discontinued Within 24 Hours - CABG
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
139
25
SCIP - Antibiotics Discontinued Within 24 Hours - CABG
1
Target:
90% compliance rate
139
25
SCIP - Antibiotics Discontinued Within 24 Hours - CABG
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
140
25
SCIP - Antibiotics Discontinued Within 24 Hours - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
140
25
SCIP - Antibiotics Discontinued Within 24 Hours - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
140
25
SCIP - Antibiotics Discontinued Within 24 Hours - Cardiac surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
140
25
SCIP - Antibiotics Discontinued Within 24 Hours - Cardiac surgery
1
Target:
90% compliance rate
140
25
SCIP - Antibiotics Discontinued Within 24 Hours - Cardiac surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
141
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
141
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
141
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hip arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
141
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hip arthroplasty
1
Target:
90% compliance rate
141
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hip arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
142
25
SCIP - Antibiotics Discontinued Within 24 Hours - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
142
25
SCIP - Antibiotics Discontinued Within 24 Hours - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
142
25
SCIP - Antibiotics Discontinued Within 24 Hours - Knee arthroplasty
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
142
25
SCIP - Antibiotics Discontinued Within 24 Hours - Knee arthroplasty
1
Target:
90% compliance rate
142
25
SCIP - Antibiotics Discontinued Within 24 Hours - Knee arthroplasty
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
143
25
SCIP - Antibiotics Discontinued Within 24 Hours - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
143
25
SCIP - Antibiotics Discontinued Within 24 Hours - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
143
25
SCIP - Antibiotics Discontinued Within 24 Hours - Colon surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
143
25
SCIP - Antibiotics Discontinued Within 24 Hours - Colon surgery
1
Target:
90% compliance rate
143
25
SCIP - Antibiotics Discontinued Within 24 Hours - Colon surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
144
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
144
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
144
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hysterectomy
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
144
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hysterectomy
1
Target:
90% compliance rate
144
25
SCIP - Antibiotics Discontinued Within 24 Hours - Hysterectomy
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
145
25
SCIP - Antibiotics Discontinued Within 24 Hours - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
145
25
SCIP - Antibiotics Discontinued Within 24 Hours - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
All selected surgical patients with no evidence of prior infection.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
145
25
SCIP - Antibiotics Discontinued Within 24 Hours - Vascular surgery
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CABG or Other Cardiac Surgery).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
145
25
SCIP - Antibiotics Discontinued Within 24 Hours - Vascular surgery
1
Target:
90% compliance rate
145
25
SCIP - Antibiotics Discontinued Within 24 Hours - Vascular surgery
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
163
30
HQA AMI Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 8 AMI hospital quality measures that shows the percentage of patients who received the recommended care for all of the measures in the set that they were eligible to receive. This set includes the following measures: AMI-1 Aspirin at Arrival; AMI-2 Aspirin at Discharge; AMI-3 ACEI or ARB for LVSD; AMI-4 Smoking Cessation Advice; AMI-5 Beta Blocker at Discharge; AMI-6 Beta Blocker at Arrival; AMI-7a Fibrinolytic Therapy Received Within 30 Min. of Arrival; AMI-8a PCI Received Within 90 Min. of Arrival
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
163
30
HQA AMI Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
The total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
163
30
HQA AMI Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
The number of patients considered compliant (measure category assignment of E for every eligible measure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
163
30
HQA AMI Composite
1
Target:
90% compliance rate
163
30
HQA AMI Composite
0
UHC FAQ Center
See Also
http://www.uhc.edu/faq/faq.asp
164
30
HQA HF Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 4 HF Hospital Quality Measures that shows the percentage of patients who received the recommended care for all of the measures in the set that they were eligible to receive. This set includes the following measures: HF-1 Discharge Instructions; HF-2 Evaluation of LVS Function; HF-3 ACEI or ARB for LVSD; HF-4 Smoking Cessation Advice.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
164
30
HQA HF Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
The total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
164
30
HQA HF Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
The number of patients considered compliant (measure category assignment of E for every eligible measure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
164
30
HQA HF Composite
1
Target:
90% compliance rate
164
30
HQA HF Composite
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.uhc.edu/faq/faq.asp
165
30
HQA PN Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 9 PN Hospital Quality Measures that shows the percentage of patients who received the recommended care for all of the measures in the set that they were eligible to receive. This set includes the following measures: The set includes the following measures: PN-1 Oxygenation Assessment; PN-2 Pneumococcal Vaccination; PN-3a Blood Cultures Performed Within 24 Hrs. of Arrival for Patients Transferred/Admitted to ICU; PN-3b Blood Cultures in ED Prior to Antibiotic (starting 2006 Q1); PN-3b Blood Cultures Before First Antibiotic (prior to 2006 Q1); PN-4 Smoking Cessation Advice; PN-5b Initial Antibiotic Rec’d Within 4 Hours of Hospital Arrival; PN-6a Antibiotic Selection for CAP in Immunocompetent ICU Patient; PN-6b Antibiotic Selection for CAP in Immunocompetent Non-ICU Patient; PN-7 Influenza Vaccination.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
165
30
HQA PN Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
The total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
165
30
HQA PN Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
The number of patients considered compliant (measure category assignment of E for every eligible measure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
165
30
HQA PN Composite
1
Target:
90% compliance rate
165
30
HQA PN Composite
0
UHC FAQ Center
See Also
http://www.uhc.edu/faq/faq.asp
166
30
HQA SCIP Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Composite metric based on 6 SCIP hospital quality measures that shows the percentage of patients who received the recommended care for all of the measures in the set that they were eligible to receive. This set includes the following measures: SCIP-Inf-1a Antibiotic Received 1 Hour prior to Surgical Incision; SCIP-Inf-2a Antibiotic Selection for Surgical Patients; SCIP-Inf-3a Antibiotics Discontinued within 24/48 Hours after Surgery End; SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 AM Postop Serum Glucose; SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal; SCIP-Inf-7 Colorectal Surgery Patients with Immediate Postop Normorthermia
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
166
30
HQA SCIP Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
The total number of patients that were eligible for at least one measure in the set (measure category assignment of D or E for one or more measures).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
166
30
HQA SCIP Composite
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
The number of patients considered compliant (measure category assignment of E for every eligible measure).
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
166
30
HQA SCIP Composite
1
Target:
90% compliance rate
166
30
HQA SCIP Composite
0
UHC FAQ Center
See Also
http://www.uhc.edu/faq/faq.asp
42
15
Influenza Vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Definition:
Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
42
15
Influenza Vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Denominator:
Pneumonia patients 50 years of age and older who were discharged during October, November, December, January or February. Exclude patients received in transfer from another acute care or critical access hospital; patients who had no working diagnosis of pneumonia at the time of admission; patients who received comfort measures only; patients who expired in the hospital; patients who left against medical advice; patients discharged to hospice care; patients with a principal or secondary diagnosis of 487.0; patients who were discharged to a federal hospital; patients who were transferred to another short-term general hospital.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
42
15
Influenza Vaccination
1
Specifications Manual for National Hospital Quality Measures, version 2.0
Numerator:
Patients discharged during October, November, December, January, or February with pneumonia, age 50 and older, who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
42
15
Influenza Vaccination
1
Target:
90% compliance rate
42
15
Influenza Vaccination
0
Specifications Manual for National Hospital Quality Measures, version 2.0
See Also
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm