Measure Comparison Selection
	 
	select measure Patient Safety for Selected Procedures Composite 
Pressure Ulcer 
Collapsed Lung caused by Medical Care 
Central Venous Catheter-related Bloodstream Infections  
Postoperative Hip Fracture  
Postoperative Hemorrhage or Hematoma 
Postoperative Respiratory Failure 
Postoperative Physiologic and Metabolic Derangement 
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) 
Postoperative Sepsis 
Wound Complications in Abdominal Wall Surgery 
Accidental Puncture and Laceration 
select measure Bypass operations only 
Valve operations or valve/bypass operations 
Angioplasty Mortality Rate 
select measure Mortality for Selected Conditions Composite 
Acute Myocardial Infarction (AMI) Mortality Rate 
Heart Failure Mortality Rate  
Gastrointestinal Hemorrhage Mortality Rate  
Hip Fracture Mortality Rate 
Pneumonia Mortality Rate  
Carotid Endarterectomy Mortality Rate 
select measure Acute Stroke Mortality 
select measure Admit decision time to ED departure time for admitted patients  
Median time from ED arrival to ED departure for discharged ED patients  
Patient left without being seen  
select measure CLABSIs, Coronary ICU 
CLABSIs, Cardiothoracic ICU 
CLABSIs, Medical ICU 
CLABSIs, Surgical ICU 
CLABSIs, Neurosurgical ICU 
CLABSIs, Pediatric ICU 
CLABSIs, Newborns Level II/III Perinatal Centers 
CLABSIs, Newborns Level III Perinatal Centers 
CLABSIs, Newborns Regional Perinatal Centers 
All Blood Stream Infections 
CLABSIs, Medical-Surgical ICU 
select measure Colon Surgery Infections 
Hip Replacement Surgery Infections 
CABG,  Chest Site Infections 
CABG,  Donor Site Infections 
Hysterectomy Surgery Infections 
All Surgical Site Infections 
select measure Percent of Patients Highly Satisfied 
Doctors Always Communicated Well 
Nurses Always Communicated Well 
Patients Always Received Help As Soon As They Wanted 
Staff Always Explained About Medicines 
Patient's Room Always Kept Quiet At Night 
Patient's Room and Bathroom Always Kept Clean 
Patients Given Information About Recovery At Home 
Patients Would Definitely Recommend This Hospital to Friends and Family 
Patients who "Agree" they understood their care when they left the hospital  
Patient Satisfaction Composite 
select measure Pneumonia Patients Readmitted to Hospital Within 30 Days 
Heart Failure Patients Readmitted to Hospital Within 30 Days 
Heart Attack Patients Readmitted to Hospital Within 30 Days 
Hospital-wide 30-day unplanned readmission rate 
select measure Patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it 
select measure Total Births 
Forceps 
Low/outlet forceps 
Mid forceps 
Internal fetal monitoring 
External fetal monitoring 
Induction - Artificial Rupture of Membranes 
Induction - Medicinal 
Augmented Labor 
Analgesia 
Attended by Licensed Midwife 
select measure Vaginal Birth After Prior Cesarean 
Breech births 
Episiotomy 
General Anesthesia 
Spinal Anesthesia 
Epidural Anesthesia 
Local/Other Anesthesia 
Paracervical Anesthesia 
Pudendal Anesthesia 
Vaginal Births 
select measure Primary Cesarean 
Repeat Cesarean 
General Anesthesia 
Spinal Anesthesia 
Epidural/Local Anesthesia 
Cesarean Births 
select measure Fed Any Breast Milk 
Fed Exclusively Breast Milk 
Breast Fed Infants Supplemented w/Formula 
select measure Administration of therapeutic substances, procedure count 
Transfusion of blood and blood products 
Transfusion of plasma 
Infusion of vasopressor 
Intravenous induction of labor 
Cervical ripening 
Vaccinations 
Chemotherapy 
Regional anesthesia 
Administration of antibiotics 
Administration of anti-inflammatory agents 
Administration of nutritional and electrolytic substances 
Administration of therapeutic substances, NEC 
select measure Cardiovascular procedures, procedure count 
Percutaneous coronary interventions (PCI) 
Angioplasty and related vessel procedures (endovascular; excluding carotid) 
Saphenous vein harvest and other therapeutic vessel removal 
Venous and arterial catheter placement 
Placement of tunneled or implantable portion of a vascular access device 
Pacemaker and defibrillator procedures 
select measure Central nervous system procedures, procedure count 
Lumbar puncture 
select measure Extracorporeal or systemic assistance and performance, procedure count 
Hemodialysis 
Mechanical ventilation 
Non-invasive ventilation 
Open heart cardiopulmonary bypass 
select measure Female reproductive system procedures, procedure count 
Salpingectomy 
select measure Gastrointestinal system procedures, procedure count 
Esophagogastroduodenoscopy (EGD) with biopsy 
Colonoscopy and proctoscopy with biopsy 
GI system endoscopy without biopsy (diagnostic) 
Paracentesis 
GI system drainage (excluding paracentesis) 
Colectomy 
Gastrectomy 
Gastrostomy 
GI system lysis of adhesions 
select measure General region procedures, procdedure count 
Abdominal wall repair (including hernia) 
select measure Hepatobiliary and pancreas procedures, procedure count 
Cholecystectomy 
select measure Imaging, procedure count 
Cardiac and coronary fluoroscopy 
Fluoroscopic angiography (excluding coronary) 
Fluoroscopy of non-circulatory organs 
Magnetic resonance imaging (MRI) 
Computerized tomography (CT) with contrast 
Computerized tomography (CT) without contrast 
Ultrasonography 
select measure Lymphatic and hemic system procedures, procedure count 
Lymph node biopsy 
select measure Measurement and monitoring, procedure count 
Measurement during cardiac catheterization 
Electroencephalogram (EEG) 
Monitoring of peripheral nerves 
select measure Mental health therapy, procedure count 
Pharmacotherapy for mental health (excluding substance use) 
Psychotherapy for mental health (excluding substance use) 
select measure Musculoskeletal, subcutaneous tissue, and fascia procedures, procedure count 
Knee arthroplasty 
Hip arthroplasty 
Femur fixation 
Spine fusion 
Vertebral discectomy 
Bone excision 
Subcutaneous tissue and fascia excision 
Perineal muscle laceration repair (2nd degree obstetrical and other) 
Subcutaneous tissue and fascia procedures, NEC 
Musculoskeletal procedures, NEC 
select measure Other procedures, procedure count 
Robotic-assisted procedures 
Isolation procedures 
select measure Pediatric administration of therapeutic substances, procedure count 
Pediatric transfusion of blood and blood products 
Pediatric transfusion of plasma 
Pediatric administration of albumin and globulin 
Pediatric intravenous induction of labor 
Pediatric vaccinations 
Pediatric chemotherapy 
Pediatric regional anesthesia 
Pediatric administration of antibiotics 
Pediatric administration of anti-inflammatory agents 
Pediatric administration of nutritional and electrolytic substances 
Pediatric irrigation (diagnostic and therapeutic) 
Pediatric administration of therapeutic substances, NEC 
select measure Pediatric cardiovascular procedures, procedure count 
Pediatric ligation and embolization of vessels 
Pediatric septal repair and other therapeutic heart procedures 
Pediatric venous and arterial catheter placement 
Pediatric placement of tunneled or implantable portion of a vascular access device 
Pediatric cardiovascular device procedures, NEC 
select measure Pediatric central nervous system procedures, procedure count 
Pediatric lumbar puncture 
Pediatric CNS procedures, NEC 
select measure Pediatric dressings and other placements, procedure count 
Pediatric immobilization by splint or other external device 
select measure Pediatric ear, nose, and throat procedures, procedure count 
Pediatric laryngoscopy (diagnostic) 
Pediatric diagnostic audiology 
Pediatric myringotomy 
Pediatric tonsillectomy and adenoidectomy 
Pediatric frenectomy 
Pediatric ENT procedures, NEC 
select measure Pediatric extracorporeal or systemic assistance and performance, procedure count 
Pediatric mechanical ventilation 
Pediatric non-invasive ventilation 
Pediatric open heart cardiopulmonary bypass 
select measure Pediatric extracorporeal or systemic therapies, procedure count 
Pediatric phototherapy 
Pediatric ultraviolet light therapy 
select measure Pediatric gastrointestinal system procedures, procedure count 
Pediatric esophagogastroduodenoscopy (EGD) with biopsy 
Pediatric colonoscopy and proctoscopy with biopsy 
Pediatric GI system drainage (excluding paracentesis) 
Pediatric appendectomy 
Pediatric gastrostomy 
Pediatric other GI system device procedures 
Pediatric upper GI therapeutic procedures, NEC (open and laparoscopic) 
select measure Pediatric imaging, procedure count 
Pediatric fluoroscopic angiography (excluding coronary) 
Pediatric fluoroscopy of non-circulatory organs 
Pediatric magnetic resonance imaging (MRI) 
Pediatric ultrasonography 
Pediatric plain radiography 
select measure Pediatric lymphatic and hemic system procedures, procedure count 
Pediatric bone marrow biopsy 
select measure Pediatric male reproductive system procedures, procedure count 
Pediatric circumcision 
select measure Pediatric measurement and monitoring, procedure count 
Pediatric arterial oxygen saturation monitoring 
Pediatric measurement during cardiac catheterization 
Pediatric cardiac monitoring 
Pediatric other cardiovascular system measurement and monitoring 
Pediatric electroencephalogram (EEG) 
Pediatric monitoring of peripheral nerves 
select measure Pediatric mental health therapy, procedure count 
Pediatric pharmacotherapy for mental health (excluding substance use) 
Pediatric psychotherapy for mental health (excluding substance use) 
select measure Pediatric musculoskeletal, subcutaneous tissue, and fascia procedures, procedure count 
Pediatric incision and drainage of subcutaneous tissue and fascia 
Pediatric fixation of upper extremity bones 
Pediatric femur fixation 
Pediatric fixation of leg and foot bones 
Pediatric bone fixation (excluding extremities) 
Pediatric spine fusion 
Pediatric bone excision 
Pediatric subcutaneous tissue and fascia excision 
Pediatric subcutaneous tissue and fascia procedures, NEC 
Pediatric musculoskeletal device procedures, NEC 
Pediatric musculoskeletal procedures, NEC 
select measure Pediatric osteopathic treatment, procedure count 
Pediatric osteopathic treatment 
select measure Pediatric other procedures, procedure count 
Pediatric isolation procedures 
select measure Pediatric pregnancy-related procedures, procedure count 
Pediatric fetal heart rate monitoring 
Pediatric spontaneous vaginal delivery 
Pediatric assisted vaginal delivery 
select measure Pediatric rehabilitation, evaluation, and treatment, procedure count 
Pediatric physical, occupational, and respiratory therapy treatment 
select measure Pediatric respiratory system procedures, procedure count 
Pediatric bronchoscopy (diagnostic) 
Pediatric chest tube placement and therapeutic thoracentesis 
Pediatric airway intubation 
Pediatric tracheostomy 
select measure Pediatric skin and breast procedures, procedure count 
Pediatric skin excision and debridement 
select measure Peripheral nervous system procedures, procedure count 
Lumbosacral nerve decompression 
select measure Pregnancy-related procedures, procedure count 
Fetal heart rate monitoring 
Spontaneous vaginal delivery 
Cesarean section 
Assisted vaginal delivery 
select measure select measure select measure Rehabilitation, evaluation, and treatment, procedure count 
Physical, occupational, and respiratory therapy treatment 
select measure Respiratory system procedures, procedure count 
Bronchoscopy (diagnostic) 
Chest tube placement and therapeutic thoracentesis 
Airway intubation 
select measure Skin and breast procedures, procedure count 
Perineal skin repair (1st degree obstetrical and other) 
select measure Substance use disorder treatment, procedure count 
Substance use detoxification 
Pharmacotherapy for substance use 
Counseling for substance use 
select measure Urinary system procedures, procedure count 
Ureter and other urinary tract dilation 
Bladder catheterization and drainage