Quality Measures Reporting Table
This quality measures table includes all of the national required and proposed quality measures for inpatient, outpatient, and ambulatory surgery center payment purposes, including the date the measure will be used for payment and when data collection must begin.

This is a complete list of indicators available to COP users. 

Mortality Indicators
- Inpatient Mortality: Total, Cardiology, Respiratory, and Following Major Cardiovascular Surgery
- Inpatient Perioperative Mortality

Infection Indicators
- Postoperative Pneumonia
- Ventilator-Associated Pneumonia for adult by type of ICU
- Primary Bloodstream Infection
- Central Line Bloodstream Infection for adult by type of ICU
- Inpatient Surgical Site Infection, Class 1 & 2, All inpatient surgeries

Unplanned Events
- Readmissions: Total, Cardiology, Respiratory and Following Major Cardiovascular Surgery
- Unplanned Return to the OR/OB Suite/Other Specialized Areas

Cesarean Sections
- Total C-sections
- Primary C-Sections
- Repeat C-Sections
- Vaginal Birth after C-Sections (VBAC)

Ambulatory Indicators
- Extended Stay Following Ambulatory Procedure

Behavioral Health Indicators
- Inpatient Mortality
- Unplanned Readmissions for Adolescent and Adult Behavioral Health Within 30 Days
- Unplanned Patient Departures
- Transfers to a Medical Care Unit During the Inpatient Stay Within 24 Hours of Admission
- Inpatients Without At Least One Outpatient Session Within 30 Days of Inpatient Discharge

Acute Myocardial Infarction
- AMI-1 Aspirin on Arrival
- AMI-2 Aspirin Prescribed at Discharge
- AMI-3 ACEI or ARB for LVSD
- AMI-5 Beta Blocker Prescribed at Discharge
- AMI-7 Median Time to Fibrinolysis
-AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
- AMI-8 Median Time to Primary PCI
-AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival
- AMI-10 Statin Prescribed at Discharge

Children’s Asthma Care
- CAC-1 Relievers for Inpatient Asthma
- CAC-2 Systemic Corticosteroids for Inpatient Asthma
- CAC-3 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver

Emergency Department
ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients
ED-2 Admit Decision Time to ED Departure Time for Admitted Patients

Hospital Based Inpatient Psychiatric Services
-HBIPS-1 Admission Screening
-HBIPS-2 Hours of Physical Restraint Use
-HBIPS-3 Hours of Seclusion Use
-HBIPS-4 Multiple Antipsychotic Medications at Discharge
-HBIPS-5 Multiple Antipsychotic Medications at Discharge with Appropriate Justification
-HBIPS-6 Post Discharge Continuing Care Plan Created
-HBIPS-7 Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider

Heart Failure
- HF-1 Discharge Instruction
- HF-2 LVF Assessment
- HF-3 ACEI or ARB for LVSD

Immunization
IMM-1 Pneumococcal Immunization
IMM-2 Influenza Immunization 

Perinatal Care Measures
- PC-1 Elective Delivery 
- PC-2 Cesarean Section
- PC-3 Antenatal Steroids
- PC-4 Health Care Associated Bloodstream Infections in Newborns
- PC-5 Exclusive Breast Milk Feeding

Pneumonia
- PN-3a Blood Cultures Within 24 Hours of Hospital Arrival, ICU
- PN-3b Blood Culture Performed in the ED Prior to First Antibiotic Received in Hospital
- PN-6a Initial Antibiotic Selection for CAP Immunocompetent-ICU
- PN-6b Initial Antibiotic Selection for CAP Immunocompetent-Non ICU

Stroke Measures
-STK-1 Stroke Patients with Venous Thromboembolism Prophylaxis
-STK-2 Discharged on Antithrombotic Therapy
-STK-3 Antiocoagulation Therapy for Artrial Fibrillation/Flutter
-STK-4 Thrombolytic Therapy
-STK-5 Antithrombotic Therapy by End of Hospital Day Two
-STK-6 Discharged on Statin Medication
-STK-8 Stroke Education
-STK-10 Assessed for Rehabilitation

Substance Use
SUB-1 Alcohol Use Screening
SUB-2 Alcohol Use Brief Intervention Provided or Offered
SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge
SUB-4 Alcohol and Drug Use: Assessing Status After Discharge

Surgical Care Improvement Project
- SCIP-Inf-1 Prophylactic Antibiotic Received within 1Hour Prior to Surgical Incision
- SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
- SCIP-Inf-3 Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time
- SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 A.M. Postoperative Serum Glucose
- SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal
- SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 with Day of Surgery Being Day Zero.
- SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management
-SCIP-Card-2 Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period
-SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery
-SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Tobacco Treatment
TOB-1 Tobacco Use Screening
TOB-2 Tobacco Use Treatment Provided or Offered
TOB-3 Tobacco Use Treatment Provided or Offered at Discharge
TOB-4 Tobacco Use: Assessing Status After Discharge

Venous Thromboemboliism Measures
-VTE-1 VTE Prophylaxis
-VTE-2 ICU VTE Prophylaxis
-VTE-3 VTE Patients with Anticoagulation Overlap Therapy
-VTE-4 VTE Patients Receiving UFH wiht Dosages/Platelet Count Monitoring by Protocol Nomogram
-VTE-5 VTE Discharge Instructions
-VTE-6 Incidence of Potentially Preventable VTE 

Hospital Outpatient Department Quality Measures
Acute Myocardial Infarction and Chest Pain
OP-1 Median Time to Fibrinolysis
OP-2 Fibrinolytic Therapy Received Within 30 Minutes
OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention
OP-4 Aspirin at Arrival
OP-5 Median Time to ECG
OP-16 Troponin results received within 60 minutes of ED arrival
ED Throughout
OP-18 Median time from ED arrival to ED departure for discharged ED patients
OP-19 Transition record with specified elements received by discharged patients
OP-20 Door to diagnostic evaluation by a qualified medical professional
Pain Management
OP-21 Median time to pain management for long bone fracture
Stroke
OP-23 Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan interpretation within 45 minutes of ED arrival
Surgical Measures
OP-6 Timing of antibiotic prophylaxis
OP-7 Prophylactic  antibiotic selection for surgical patients
OP-7 Antibiotic Selection