Improvement Activities Fact Sheet
(TOTAL MAXIMUM SCORE 40)
Groups with more than 15 clinicians
Each activity is weighted either medium or high. To get the maximum score of 40 points for the Improvement Activity score, you may select any of these combinations:
TWO high-weighted activities
ONE high-weighted activity and 2 medium-weighted activities
FOUR medium-weighted activities
“Each medium-weighted activity is worth 10 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 20 points of the total category score”
Groups with 15 or fewer clinicians, non-patient facing
clinicians and/or clinicians located in a rural area or
HPSA
Each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activity score, you may select either of these combinations:
ONE high-weighted activity
TWO medium-weighted activities
Each medium-weighted activity is worth 20 points and a high-weighted activity is worth 40 points.
You may select two medium-weighted activities or one high-weighted activity to receive a total of 40 points of the total category score.
“Each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 40 points of the total category score”
- KEY POINTS:
The Improvement Activity performance category counts for 15% of your MIPS final score - You must attest by indicating “Yes” to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the current performance period).
- Eligible clinicians are encouraged to retain documentation for 6 years as required by the CMS document retention policy.
- You may report activities using a qualified registry, via certified EHR Technology), qualified clinical data
registry (QCDR), the CMS Web Interface (for groups of 25 or more), or via attestation. These
intermediaries will need to certify that you performed the activities as indicated
For more information click on this link for MIPS FACT SHEET
For choosing MIPS IMPROVEMENT ACTIVITIES CLICK ON LINK BELOW:
Instructions
- Review and select activities that best fit your practice.
- Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
- Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
- Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
SUMMARY
There are 93 categories to choose from. Out of 93, 13 or high weighted. 80 re medium weighted. High weighted are marked in bold and orange color to identify them easily.
- Additional improvements in access as a result of QIN/QIO TA
- Administration of the AHRQ Survey of Patient Safety Culture
- Annual registration in the Prescription Drug Monitoring Program
- Anticoagulant management improvements
- Care coordination agreements that promote improvements in patient tracking across settings
- Care transition documentation practice improvements
- Care transition standard operational improvements
- Chronic care and preventative care management for empanelled patients
- CMS partner in Patients Hospital Improvement Innovation Networks
- Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
- Collection and use of patient experience and satisfaction data on access
- Completion of the AMA STEPS Forward program
- Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
- Consultation of the Prescription Drug Monitoring program
- Depression screening
- Diabetes screening
- Electronic Health Record Enhancements for BH data capture
- Engage patients and families to guide improvement in the system of care.
- Engagement of community for health status improvement
- Engagement of new Medicaid patients and follow-up
- Engagement of patients through implementation of improvements in patient portal
- Engagement of patients, family and caregivers in developing a plan of care
- Engagement with QIN-QIO to implement self-management training programs
- Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
- Evidenced-based techniques to promote self-management into usual care
- Glycemic management services
- Implementation of additional activity as a result of TA for improving care coordination
- Implementation of analytic capabilities to manage total cost of care for practice population
- Implementation of antibiotic stewardship program
- Implementation of co-location PCP and MH services
- Implementation of condition-specific chronic disease self-management support programs
- Implementation of documentation improvements for practice/process improvements
- Implementation of episodic care management practice improvements
- Implementation of fall screening and assessment programs
- Implementation of formal quality improvement methods, practice changes or other practice improvement processes
- Implementation of improvements that contribute to more timely communication of test results
- Implementation of integrated PCBH model
- Implementation of medication management practice improvements
- Implementation of methodologies for improvements in longitudinal care management for high risk patients
- Implementation of practices/processes for developing regular individual care plans
- Implementation of use of specialist reports back to referring clinician or group to close referral loop
- Improved practices that disseminate appropriate self-management materials
- Improved practices that engage patients pre-visit
- Integration of patient coaching practices between visits
- Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
- Leveraging a QCDR for use of standard questionnaires
- Leveraging a QCDR to promote use of patient-reported outcome tools
- Leveraging a QCDR to standardize processes for screening
- MDD prevention and treatment interventions
- Measurement and improvement at the practice and panel level
- Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.
- Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
- Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
- Participation in a QCDR, that promotes implementation of patient self-action plans.
- Participation in a QCDR, that promotes use of patient engagement tools.
- Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.
- Participation in an AHRQ-listed patient safety organization.
- Participation in Bridges to Excellence or other similar program
- Participation in CAHPS or other supplemental questionnaire
- Participation in CMMI models such as Million Hearts Campaign
- Participation in Joint Commission Evaluation Initiative
- Participation in MOC Part IV
- Participation in population health research
- Participation in private payer CPIA
- Participation in systematic anticoagulation program
- Participation on Disaster Medical Assistance Team, registered for 6 months.
- Patient Centered Medical Home Attestation
- Population empanelment
- Practice improvements for bilateral exchange of patient information
- Practice improvements that engage community resources to support patient health goals
- Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record
- Provide peer-led support for self-management.
- Regular review practices in place on targeted patient population needs
- Regular training in care coordination
- Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
- RHC, IHS or FQHC quality improvement activities
- TCPI participation
- Tobacco use
- Unhealthy alcohol use
- Use evidence-based decision aids to support shared decision-making.
- Use group visits for common chronic conditions (e.g., diabetes).
- Use of certified EHR to capture patient reported outcomes
- Use of decision support and standardized treatment protocols
- Use of patient safety tools
- Use of QCDR data for ongoing practice assessment and improvements
- Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
- Use of QCDR for feedback reports that incorporate population health
- Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.
- Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
- Use of QCDR to support clinical decision making
- Use of telehealth services that expand practice access
- Use of tools to assist patient self-management
- Use of toolsets or other resources to close healthcare disparities across communities
Quality Measures
Instructions
- Review and select measures that best fit your practice.
- “Add up to six measures from the list below, including one outcome measure”. You can use the search and filters to help find the measures that meet your needs or specialty.
- If an outcome measure is not available that is applicable to your specialty or practice, chose another high priority measure.
- Download a CSV file of the measures you have selected for your records.
DETAIL:
SUMMARY
- Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
- Acute Otitis Externa (AOE): Topical Therapy
- ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
- Adherence to Antipsychotic Medications For Individuals with Schizophrenia
- Adult Kidney Disease: Blood Pressure Management
- Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis
- Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days
- Adult Kidney Disease: Referral to Hospice
- Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
- Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
- Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
- Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
- Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
- Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
- Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
- Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
- Age Appropriate Screening Colonoscopy
- Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
- Age-Related Macular Degeneration (AMD): Dilated Macular Examination
- All-cause Hospital Readmission
- Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
- Anastomotic Leak Intervention
- Anesthesiology Smoking Abstinence
- Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
- Anti-Depressant Medication Management
- Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
- Appropriate Follow-up Imaging for Incidental Abdominal Lesions
- Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
- Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
- Appropriate Testing for Children with Pharyngitis
- Appropriate Treatment for Children with Upper Respiratory Infection (URI)
- Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia
- Appropriate Workup Prior to Endometrial Ablation
- Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
- Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
- Barrett’s Esophagus
- Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician
- Biopsy Follow-Up
- Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use
- Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
- Breast Cancer Screening
- CAHPS for MIPS Clinician/Group Survey
- Cardiac Rehabilitation Patient Referral from an Outpatient Setting
- Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients
- Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
- Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
- Care Plan
- Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)
- Cataract Surgery: Difference Between Planned and Final Refraction
- Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
- Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
- Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
- Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
- Cervical Cancer Screening
- Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
- Childhood Immunization Status
- Children Who Have Dental Decay or Cavities
- Chlamydia Screening and Follow Up
- Chlamydia Screening for Women
- Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy
- Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
- Clinical Outcome Post Endovascular Stroke Treatment
- Closing the Referral Loop: Receipt of Specialist Report
- Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
- Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
- Colorectal Cancer Screening
- Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older
- Controlling High Blood Pressure
- Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
- Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
- Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
- Coronary Artery Bypass Graft (CABG): Prolonged Intubation
- Coronary Artery Bypass Graft (CABG): Stroke
- Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
- Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery
- Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
- Coronary Artery Disease (CAD): Antiplatelet Therapy
- Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
- Dementia: Caregiver Education and Support
- Dementia: Cognitive Assessment
- Dementia: Counseling Regarding Safety Concerns
- Dementia: Functional Status Assessment
- Dementia: Management of Neuropsychiatric Symptoms
- Dementia: Neuropsychiatric Symptom Assessment
- Depression Remission at Six Months
- Depression Remission at Twelve Months
- Depression Utilization of the PHQ-9 Tool
- Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
- Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
- Diabetes: Eye Exam
- Diabetes: Foot Exam
- Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
- Diabetes: Medical Attention for Nephropathy
- Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
- Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
- Documentation of Current Medications in the Medical Record
- Documentation of Signed Opioid Treatment Agreement
- Door to Puncture Time for Endovascular Stroke Treatment
- Elder Maltreatment Screen and Follow-Up Plan
- Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
- Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
- Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
- Evaluation or Interview for Risk of Opioid Misuse
- Falls: Plan of Care
- Falls: Risk Assessment
- Falls: Screening for Future Fall Risk
- Follow-Up After Hospitalization for Mental Illness (FUH)
- Functional Outcome Assessment
- Functional Status Assessment for Total Hip Replacement
- Functional Status Assessment for Total Knee Replacement
- Functional Status Assessments for Congestive Heart Failure
- Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
- Functional Status Change for Patients with Foot or Ankle Impairments
- Functional Status Change for Patients with General Orthopaedic Impairments
- Functional Status Change for Patients with Hip Impairments
- Functional Status Change for Patients with Knee Impairments
- Functional Status Change for Patients with Lumbar Impairments
- Functional Status Change for Patients with Shoulder Impairments
- Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
- Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
- Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
- Hematology: Multiple Myeloma: Treatment with Bisphosphonates
- Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow
- Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy
- Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
- Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
- HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies
- HIV Medical Visit Frequency
- HIV Viral Load Suppression
- HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
- HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
- HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
- HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate
- HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
- Hypertension: Improvement in Blood Pressure
- Image Confirmation of Successful Excision of Image-Localized Breast Lesion
- Immunizations for Adolescents
- Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
- Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment
- Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
- Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
- Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
- KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
- Lung Cancer Reporting (Biopsy/Cytology Specimens)
- Lung Cancer Reporting (Resection Specimens)
- Maternal Depression Screening
- Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)
- Maternity Care: Post-Partum Follow-Up and Care Coordination
- Medication Management for People with Asthma
- Medication Reconciliation Post-Discharge
- Melanoma Reporting
- Melanoma: Continuity of Care – Recall System
- Melanoma: Coordination of Care
- Melanoma: Overutilization of Imaging Studies in Melanoma
- Non-Recommended Cervical Cancer Screening in Adolescent Females
- Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
- Oncology: Medical and Radiation – Pain Intensity Quantified
- Oncology: Medical and Radiation – Plan of Care for Pain
- Oncology: Radiation Dose Limits to Normal Tissues
- One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
- Operative Mortality Stratified by the Five STS-EACTS Mortality Categories
- Opioid Therapy Follow-up Evaluation
- Optimal Asthma Control
- Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
- Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
- Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
- Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
- Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
- Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description
- Osteoarthritis (OA): Function and Pain Assessment
- Osteoporosis Management in Women Who Had a Fracture
- Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination
- Pain Assessment and Follow-Up
- Pain Brought Under Control Within 48 Hours
- Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
- Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
- Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease
- Parkinson’s Disease: Rehabilitative Therapy Options
- Patient-Centered Surgical Risk Assessment and Communication
- Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
- Pediatric Kidney Disease: Adequacy of Volume Management
- Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL
- Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence
- Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
- Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
- Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy
- Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
- Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
- Perioperative Temperature Management
- Persistence of Beta-Blocker Treatment After a Heart Attack
- Photodocumentation of Cecal Intubation
- Pneumococcal Vaccination Status for Older Adults
- Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
- Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
- Pregnant women that had HBsAg testing
- Preoperative Diagnosis of Breast Cancer
- Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
- Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
- Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
- Preventive Care and Screening: Influenza Immunization
- Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
- Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
- Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
- Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
- Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
- Proportion Admitted to Hospice for less than 3 days
- Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life
- Proportion Not Admitted To Hospice
- Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
- Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
- Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair
- Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life
- Proportion Receiving Chemotherapy in the Last 14 Days of Life
- Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer
- Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
- Psoriasis: Clinical Response to Oral Systemic or Biologic Medications
- Quality of Life Assessment For Patients With Primary Headache Disorders
- Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients
- Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
- Radical Prostatectomy Pathology Reporting
- Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy
- Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms
- Radiology: Reminder System for Screening Mammograms
- Radiology: Stenosis Measurement in Carotid Imaging Reports
- Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
- Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
- Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital
- Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)
- Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive
- Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)
- Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
- Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA)
- Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure
- Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
- Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
- Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
- Rheumatoid Arthritis (RA): Functional Status Assessment
- Rheumatoid Arthritis (RA): Glucocorticoid Management
- Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
- Rheumatoid Arthritis (RA): Tuberculosis Screening
- Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
- Screening Colonoscopy Adenoma Detection Rate
- Screening for Osteoporosis for Women Aged 65-85 Years of Age
- Sentinel Lymph Node Biopsy for Invasive Breast Cancer
- Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
- Sleep Apnea: Assessment of Sleep Symptoms
- Sleep Apnea: Positive Airway Pressure Therapy Prescribed
- Sleep Apnea: Severity Assessment at Initial Diagnosis
- Statin Therapy at Discharge after Lower Extremity Bypass (LEB)
- Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
- Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
- Stroke and Stroke Rehabilitation: Thrombolytic Therapy
- Surgical Site Infection (SSI)
- Tobacco Use and Help with Quitting Among Adolescents
- Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
- Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
- Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
- Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
- Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy
- Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
- Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
- Unplanned Hospital Readmission within 30 Days of Principal Procedure
- Unplanned Reoperation within the 30 Day Postoperative Period
- Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
- Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
- Use of High-Risk Medications in the Elderly
- Use of Imaging Studies for Low Back Pain
- Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
