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Quality Initiatives

Quality initiatives by department.

Administrative

  • Access the CI portal
  • Complete IT/BI tool training
  • Physician query response within 48 hours
  • Medical record delinquency
  • Communication with doctors
  • First-case on-time starts
  • CPOE order set utilization
  • Medication reconciliation: Reconciliation after discharge from an inpatient facility
  • Advance care plan
  • Length of stay
  • Readmissions—30-day all-cause
  • Readmissions—30-day all-cause—CHF, AMI, PN

Allergy

  • Asthma: Pharmacologic therapy for persistent asthma
  • Asthma: Assessment of asthma control
  • Pharyngitis: Appropriate testing for children with pharyngitis
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

Anesthesiology

  • Ventilator-associated pneumonia
  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Perioperative beta-blocker
  • Prophylactic antibiotic selection for surgical patients (outpatient)
  • Perioperative temperature management

Cardiology

  • Acute myocardial infarction appropriateness of care score
  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • Pneumococcal immunization—overall rate
  • Influenza immunization
  • All-cause readmissions
  • Median time to transfer to another facility for acute coronary intervention—AMI patients only
  • Coronary artery disease (CAD): Antiplatelet therapy
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco use assessment and tobacco cessation intervention
  • At-risk population—hypertension (HTN): Controlling high blood pressure
  • Atrial fibrillation and atrial flutter: Chronic anticoagulation therapy

Dermatology

  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Adult weight screening and follow-up
  • Melanoma: Continuity of care—recall system
  • Melanoma: Coordination of care
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

Emergency medicine

  • Emergency medicine: 12-lead electrocardiogram (ECG) performed for non-traumatic chest pain
  • Emergency medicine: 12-lead electrocardiogram (ECG) performed for syncope
  • Acute myocardial infarction appropriateness of care score
  • Pneumonia appropriateness of care score
  • Door to diagnostic evaluation by qualified medical personnel
  • ED—median time to pain management for long bone fracture
  • Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan results within 45 minutes of arrival
  • Median time to transfer to another facility for acute coronary intervention—AMI patients only
  • Emergency department throughput: Median time from ED arrival to ED departure for admitted ED patients
  • Emergency department throughput: Admitted patients—admit decision time to ED departure time for admitted patients
  • All-cause readmissions

ENT

  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • Venous thromboembolism prophylaxis
  • Surgical site infections—overall composite
  • C-diff infections
  • Prophylactic antibiotic selection for surgical patients
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • All-cause readmissions

Family practice and internal medicine

  • Diabetes mellitus: Hemoglobin A1C poor control in diabetes mellitus > 9 percent
  • Diabetes mellitus: High blood pressure control in diabetes mellitus
  • Asthma: Pharmacologic therapy for persistent asthma
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Mammography screening
  • Preventive health: Colorectal cancer screening
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Depression screening
  • Diabetes mellitus: Foot exam
  • Preventive health: Tobacco=use assessment and tobacco cessation intervention

Gastroenterology

  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • C-diff infections
  • All-cause readmissions
  • Hepatitis C: Counseling regarding risk of alcohol consumption
  • Preventive health: Colorectal cancer screening
  • Preventive health: Adult weight screening and follow-up
  • Hepatitis C: Hepatitis A vaccination in patients with HCV
  • Hepatitis C: Hepatitis B vaccination in patients with HCV
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

General surgery

  • Emergency department throughput—median time from ED arrival to ED departure for admitted ED patients
  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • Surgical site infections—overall composite
  • C-diff infections
  • Central-line associated bloodstream infections
  • Prophylactic antibiotic selection for surgical patients
  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • All-cause readmissions
  • Perioperative pulmonary embolus or deep venous thrombosis rate
  • Accidental puncture or laceration rate

Hematology and oncology

  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • C-diff infections
  • All-cause readmissions
  • Hematology: Multiple myeloma: Treatment with bisphosphonates
  • Cancer care: Breast cancer: Hormonal therapy for stage IC-IIIC estrogen receptor/progesterone receptor (ER/PR) positive breast cancer
  • Cancer care: Colon cancer: Chemotherapy for stage III colon cancer patients
  • Prostate cancer: Avoidance of overuse of bone scan for staging low-risk prostate cancer patients
  • Cancer care: Prostate cancer: Adjuvant hormonal therapy for high-risk prostate cancer patients
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Depression screening
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

HIV/AIDS

  • Hepatitis C: Confirmation of hepatitis C viremia
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive care and screening: Screening for clinical depression and follow-up plan
  • HIV/AIDS: CD4+ cell count or CD4+ percentage performed
  • HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) prophylaxis
  • Hepatitis C: Hepatitis A vaccination in patients with hepatitis C virus (HCV)
  • HIV/AIDS: Sexually transmitted disease screening for chlamydia, gonorrhea and syphilis
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • HIV viral load suppression
  • Prescription of HIV antiretroviral therapy
  • HIV medical visit frequency
  • Gap in HIV medical visits
  • HIV/AIDS: Medical visit
  • HIV/AIDS: RNA control for patients with HIV

Hospitalists

  • Acute myocardial infarction appropriateness of care score
  • Heart failure appropriateness of care score
  • Pneumonia appropriateness of care score
  • Venous thromboembolism (VTE) prophylaxis
  • Ischemic stroke: Anticoagulant therapy for atrial fibrillation/flutter
  • Ischemic stroke: Discharged on statin medication
  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • Pneumococcal immunization—overall rate
  • Influenza immunization
  • Surgical site infections—overall composite
  • Ventilator-associated pneumonia
  • C-diff infections
  • Emergency department throughput—median time from ED arrival to ED departure for admitted ED patients
  • Emergency department throughput—admitted patients—admit decision time to ED departure time for admitted patients
  • All-cause readmissions
  • Stroke and stroke rehabilitation: Deep vein thrombosis (DVT) prophylaxis for ischemic stroke or intracranial hemorrhage
  • Stroke and stroke rehabilitation: Screening for dysphagia
  • Stroke and stroke rehabilitation: Rehabilitation services ordered

Infectious disease

  • Prophylactic antibiotic selection for surgical patients—overall rate
  • C-diff infections
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • Chronic wound care: Use of wound surface culture technique in patients with chronic skin ulcers (overuse measure)

Nephrology

  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Diabetes mellitus: Medical attention for nephropathy
  • Adult kidney disease: Laboratory testing (lipid profile)
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • At-risk population: Hypertension (HTN): Controlling high blood pressure

Neurology

  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • All-cause readmissions
  • Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan results within 45 minutes of arrival
  • Emergency department throughput—median time from ED arrival to ED departure for admitted ED patients
  • Emergency department throughput—admitted patients—admit decision time to ED departure time for admitted patients
  • Venous thromboembolism (VTE) prophylaxis
  • Ischemic stroke: Anticoagulant therapy for atrial fibrillation/flutter
  • Ischemic stroke: Discharged on statin medication
  • Stroke and stroke rehabilitation: Discharged on antithrombotic therapy
  • Advance care plan
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Depression screening
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • Epilepsy: Documentation of etiology of epilepsy or epilepsy syndrome

OB-GYN

  • Venous thromboembolism prophylaxis
  • Surgical-site infections—overall composite
  • Elective delivery
  • Exclusive breast milk feeding
  • Prophylactic antibiotic selection for surgical patients
  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • All-cause readmissions
  • Screening or therapy for osteoporosis for women age 65 years and older
  • Preventive health: Influenza immunization
  • Preventive health: Pneumococcal vaccination
  • Preventive health: Mammography screening
  • Preventive health: Colorectal cancer screening
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • Cervical cancer screening
  • Chlamydia screening for women
  • Preventive health: Screening for high blood pressure
  • Perioperative pulmonary embolus or deep venous thrombosis rate
  • Accidental puncture or laceration rate

Ophthalmology

  • Primary open-angle glaucoma (POAG): Optic nerve evaluation
  • Age-related macular degeneration (AMD): Dilated macular examination
  • Diabetes mellitus: Dilated eye exam in a diabetic patient
  • Primary open-angle glaucoma (POAG): Reduction of intraocular pressure (IOP) by 15 percent or documentation of a plan of care

Orthopedics

  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • Surgical-site infections—overall composite
  • C-diff infections
  • All-cause readmissions
  • Prophylactic antibiotic selection for surgical patients (outpatient)
  • Osteoporosis: Management following fracture of hip, spine or distal radius for men and women age 50 years and older
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

Pain management

  • Pain assessment and follow-up
  • Preventive care and screening: Unhealthy alcohol use—screening
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention
  • Substance use disorders: Counseling regarding psychosocial and pharmacologic treatment options for alcohol dependence
  • Substance use disorders: Screening for depression among patients with substance abuse or dependence

Pathology

  • Surgical margins
  • Biopsy correlation postsurgical report
  • Communication of unexpected findings
  • Surgical pathology turnaround time—frozen sections
  • Breast cancer resection pathology reporting: pT category (primary tumor) and pN category (regional lymph nodes) with histologic grade
  • Colorectal cancer resection pathology reporting: pT (primary tumor) and pN category (regional lymph nodes) with histologic grade
  • Oncology: Cancer stage documented
  • Barrett's esophagus

Pediatrics

  • Well-child visits—first 15 months
  • Well-child visits—years 3, 4, 5 and 6
  • Well-care—adolescent
  • Well care visits—adolescent—HPV vaccine
  • Asthma: Pharmacologic therapy for persistent asthma
  • Asthma: Assessment of asthma control
  • Pharyngitis: Appropriate testing for children with pharyngitis
  • Preventive health: Influenza immunization
  • Weight assessment and counseling for nutrition and physical activity for children and adolescents
  • All-cause readmissions

Podiatry

  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • Venous thromboembolism prophylaxis
  • Surgical-site infections—overall composite
  • Prophylactic antibiotic selection for surgical patients (outpatient)
  • Preventive health: Adult weight screening and follow-up
  • Pain assessment and follow-up
  • Diabetes mellitus: Foot exam
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

Radiation oncology

  • Advance care plan
  • Breast cancer: Hormonal therapy for stage IC-IIIC estrogen receptor/progesterone receptor (ER/PR) positive breast cancer
  • Prostate cancer: Avoidance of overuse of bone scan for staging low-risk prostate cancer patients
  • Prostate cancer: Adjuvant hormonal therapy for high-risk prostate cancer
  • Preventive health: Adult weight screening and follow-up
  • Oncology: Cancer stage documented
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention

Radiology—diagnostic and interventional

  • Radiology: Exposure time reported for procedures using fluoroscopy
  • Radiology: Inappropriate use of "probably benign" assessment category in mammography screening
  • Nuclear medicine: Correlation with existing imaging studies for all patients undergoing bone scintigraphy
  • Radiology: Stenosis measurement in carotid imaging reports
  • ED—median time to pain management for long bone fracture
  • Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan results within 45 minutes of arrival
  • Emergency department throughput—median time from ED arrival to ED departure for admitted ED patients
  • Radiology turnaround times

Urology

  • Prophylactic antibiotic selection for surgical patients—overall rate
  • Surgery patients who received appropriate venous thromboembolism within 24 hours prior to surgery to 24 hours after surgery
  • Perioperative beta-blocker
  • Venous thromboembolism prophylaxis
  • Intensive care unit venous thromboembolism prophylaxis
  • Emergency department throughput—median time from ED arrival to ED departure for admitted ED patients
  • Surgical-site infections—overall composite
  • C-diff infections
  • All-cause readmissions
  • Prophylactic antibiotic selection for surgical patients (outpatient)
  • Urinary incontinence: Assessment of presence or absence of urinary incontinence in women aged 65 years and older
  • Urinary incontinence: Characterization of urinary incontinence in women age 65 years and older
  • Preventive health: Adult weight screening and follow-up
  • Preventive health: Tobacco-use assessment and tobacco cessation intervention