Administration of ASA to AMI pts on arrival to ED
| Measure Description | ASA to AMI Patients Upon Arrival |
| Denominator Description | Patients with an ED discharge dx of acute myocardial infarction (AMI) |
| Numerator Description | Patients w/ documentation of receiving aspirin on arrival or during ED stay |
| Exception Description | None |
| Exclusion Description | None |
Advance Care Plan
| Measure Description | Patients aged 65 years and older who have an advance care plan or surrogate decision maker documented |
| Denominator Description | Pts >=65 Yrs w/ encounter during performance period |
| Numerator Description | Advance care planning documentation |
| Exception Description | None |
| Exclusion Description | None |
Annual Wellness Visit
| Measure Description | Patients >= 66 Years With Annual Wellness Visit Documented Within 12 Months |
| Denominator Description | Patients >= 66 Years With Encounter in 12 Months |
| Numerator Description | Annual Wellness Visit Documented Within 12 Months |
| Exception Description | None |
| Exclusion Description | None |
Anticoagulant Recommended at Discharge for Stroke Patients
| Measure Description | Anticoagulant Recommended at Discharge for Stroke Patients |
| Denominator Description | Number of stroke patients seen by neurologist |
| Numerator Description | Stroke pts w/ atrial fib/flutter who received anticoagulant recommendation on discharge |
| Exception Description | None |
| Exclusion Description | None |
Asthma Controller Medication for Persistent Asthma patients
| Measure Description | Patients ages 5-64 w/Persistent Asthma DX Prescribed Asthma Controller Medication within 12 months |
| Denominator Description | Pts ages 5-64 w/Persistent Asthma DX within 12 months |
| Numerator Description | Appropriately prescribed medication within 12 months |
| Exception Description | None |
| Exclusion Description | Comorbid Conditions |
Avoidance of Simultaneous Use of Brain & Sinus CT at ER Visit
| Measure Description | Avoidance of Simultaneous Use of Brain & Sinus CT at ER Visit |
| Denominator Description | Patients with Eligible Emergency Room Visit w/Brain CT in 12 Mos |
| Numerator Description | Patients Had Brain CT Only AND No Sinus CT Same ER Visit |
| Exception Description | None |
| Exclusion Description | None |
Blood Pressure Measurement
| Measure Description | Pts >=3 Yrs with BP documented in 12 months |
| Denominator Description | Patients aged >= 3 years & Visit within 12 months |
| Numerator Description | BP measurement within 12 months |
| Exception Description | None |
| Exclusion Description | None |
Breast Cancer Screening
| Measure Description | Patient Age (40-74 Years) - Screening Mammogram (QHP) |
| Denominator Description | Females aged 42-74 w/ Visit in 12 Mos |
| Numerator Description | Mammogram performed within 27 months |
| Exception Description | Patients other than Female |
| Exclusion Description | Mastectomy |
Cervical Cancer Screening
| Measure Description | Women 21-64 Yrs Received PAP in 3 years OR HPV in 5 years (>=30 years) |
| Denominator Description | Women Age 21-64 years with Encounter in 12 months |
| Numerator Description | PAP in 3 years OR HPV in 5 Year (>=30yrs) |
| Exception Description | Patients other than Female |
| Exclusion Description | Hospice / Hysterectomy |
Child and Adolescent Well Care Visits
Child and Adolescent Well Care Visits (3-11 Years)
| Measure Description | Patients Age 3-11 Years with at Least 1 well-care visit in 12 Months |
| Denominator Description | Patients Aged 3-11 Years |
| Numerator Description | At Least 1 Well-Care Visit in 12 Months |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Child and Adolescent Well Care Visits (12-17 Years)
| Measure Description | Patients Age 12-17 Years with at Least 1 well-care visit in 12 Months |
| Denominator Description | Patients Aged 12-17 Years |
| Numerator Description | At Least 1 Well-Care Visit in 12 Months |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Child and Adolescent Well Care Visits (18-21 Years)
| Measure Description | Patients Age 18-21 Years with at Least 1 well-care visit in 12 Months |
| Denominator Description | Patients Aged 18-21 Years |
| Numerator Description | At Least 1 Well-Care Visit in 12 Months |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Child and Adolescent Well Care Visits (3-21 Years)
| Measure Description | [BONUS] Child and Adolescent Well Care Visits (3-21 Years) |
| Denominator Description | Patients Aged 3-21 Years |
| Numerator Description | At Least 1 Well-Care Visit in 12 Months |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Colorectal Cancer Screening
| Measure Description | Patients ages 46-75 with at Least 1 Visit in 12 Months Screened for Colorectal Cancer |
| Denominator Description | Patients ages 46-75 with at Least 1 Visit in 12 Months |
| Numerator Description | FOBT/FIT-DNA/Colonography/Flex Sigmoidoscopy/Colonoscopy |
| Exception Description | None |
| Exclusion Description | Total Colectomy/Colon Cancer/Hospice Care |
Controlling High Blood Pressure (<140/90) for Hypertension
| Measure Description | Pts >=18 Yrs with HTN DX With Most Recent BP <140/90 in 12 Mos |
| Denominator Description | Pts >=18 yrs w/ HTN DX in last 24 Months w/ at least 1 Visit in 12 mos |
| Numerator Description | Blood Pressure < 140/90 at the most recent visit (Not Inpt or ED) |
| Exception Description | None |
| Exclusion Description | Hospice/Dx of Preg/ESRD/Chronic Kidneys/Vascular access/Kidney transplant |
Diabetic Eye Exam
| Measure Description | Pts 18 - 75 Yrs with Diabetes Diagnosis Who Received DM Eye Exam w/in 12 Mos OR Negative Retinopathy in 24 Months |
| Denominator Description | Pts >=18 & <=75 yrs w/ Diabetes DX & at least 1 visit in 12 months |
| Numerator Description | Received DM Eye Exam w/in 12 Mos OR Negative Retinopathy in 24 Months |
| Exception Description | None |
| Exclusion Description | Hospice/GestDM |
Diabetic Foot Exam
| Measure Description | Pts 18 - 75 Yrs with Diabetes Diagnosis Who Received Foot Exam (Visual, Sensory & Pulse) w/in 12 Mos |
| Denominator Description | Pts >=18 & <=75 yrs w/ Diabetes DX & at least 1 visit in 12 months |
| Numerator Description | Received Foot Exam (Visual, Sensory & Pulse) w/in 12 Mos |
| Exception Description | None |
| Exclusion Description | Bilateral amputation/Hospice |
Flu Vaccine, 2025
| Measure Description | Pts >=50 Yrs Who Received Flu Vaccine Jul 2024-Jun 2025 |
| Denominator Description | Age > 50 years with Encounter in 12 Mos |
| Numerator Description | Flu Vaccine Between July 1, 2024 and June 30, 2025 |
| Exception Description | Pt Refused/Contraindications |
| Exclusion Description | None |
Glycemic Status Assessment for Diabetic Patients (A1c)
| Measure Description | Pts 18 - 75 Yrs with Diabetes Diagnosis With HbA1c Test Performed in 12 Months |
| Denominator Description | Pts >=18 & <=75 yrs w/ Diabetes DX & at least 1 visit in 12 months |
| Numerator Description | HbA1c Test w/in 12 Mos |
| Exception Description | None |
| Exclusion Description | Hospice/GestDM |
HbA1c Well Controlled (<8%) for Diabetic Patients
| Measure Description | Pts 18 - 75 Yrs with Diabetes Diagnosis With HbA1c Under Control (<8%) |
| Denominator Description | Pts >=18 & <=75 yrs w/ Diabetes DX & at least 1 visit in 12 months |
| Numerator Description | Latest HbA1c <8% in 12 Months |
| Exception Description | None |
| Exclusion Description | Hospice/GestDM |
Hospital Visit w/in 7 days After OP Surgery
| Measure Description | Hospital Visit w/in 7 days After OP Surgery |
| Denominator Description | Patients w/Outpatient Surgery in 12 Months |
| Numerator Description | Patients w/Hospital Visit w/in 7 Days After OP Surgery |
| Exception Description | None |
| Exclusion Description | Elective |
Immunizations for Adolescents
Immunizations for Adolescents (Combo 2)
| Measure Description | [BONUS] Immunizations for Adolescents (Combo 2) |
| Denominator Description | Age=13 years |
| Numerator Description | Patients who had 1 dose of Meningococcal & 1 dose of Tdap & 2 or 3 dose of HPV |
| Exception Description | None |
| Exclusion Description | Anaphylactic Reaction to Vaccine, Tdap Encephalopathy, Hospice Members |
Immunizations for Adolescents (HPV)
| Measure Description | Immunizations for Adolescents -At least 2 or 3 doses of HPV (Human Papilloma Virus) |
| Denominator Description | Age=13 years |
| Numerator Description | Appropriate doses of HPV(2 or 3 doses) |
| Exception Description | None |
| Exclusion Description | Anaphylactic Reaction to Vaccine, Tdap Encephalopathy, Hospice Members |
Immunizations for Adolescents (Meningococcal)
| Measure Description | Immunizations for Adolescents (Meningococcal) |
| Denominator Description | Age=13 years |
| Numerator Description | At least One Meningococcal |
| Exception Description | None |
| Exclusion Description | Anaphylactic Reaction to Vaccine, Tdap Encephalopathy, Hospice Members |
Immunizations for Adolescents (Tdap)
| Measure Description | Immunizations for Adolescents (Tetanus, Diphtheria Toxoids and Acellular Pertussis) |
| Denominator Description | Age=13 years |
| Numerator Description | At least OneTdap |
| Exception Description | None |
| Exclusion Description | Anaphylactic Reaction to Vaccine, Tdap Encephalopathy, Hospice Members |
Kidney Health Evaluation for Diabetic Patients
| Measure Description | Pts 18-75 Yrs with Diabetes DX who received a Kidney Health Evaluation in 12 Months |
| Denominator Description | Pts >=18 & <=75 yrs w/ Diabetes DX & at least 1 visit in 12 months |
| Numerator Description | Patients who received a Kidney Health Evaluation w/in 12 Mos |
| Exception Description | None |
| Exclusion Description | Hospice/GestDM/Preg/ESRD/Chronic Kidney/Kidney Transplant |
Lipid Profile for Adult Kidney Disease
| Measure Description | Pts age >= 18 years w/ Dx of CKD Stage 3, 4 or 5 and not receiving RRT who had a fasting lipid profile performed at least once w/in 12-month period |
| Denominator Description | Pts age >= 18 years w/ Dx of CKD Stage 3, 4 or 5 and not receiving RRT |
| Numerator Description | Pts who had a fasting lipid profile performed at least once w/in 12-month period |
| Exception Description | None |
| Exclusion Description | Documentation of patient reason(s) for not performing a fasting lipid profile |
Nosocomial Infection Rate in NICU
| Measure Description | Nosocomial Infection Rate in NICU |
| Denominator Description | Number of patients seen by neonatologist |
| Numerator Description | Number of patients seen by neonatologist who develop nosocomial infections |
| Exception Description | None |
| Exclusion Description | None |
One-Time Screening for Hepatitis C Virus
| Measure Description | Pts >= 18 yrs who received screening for Hepatitis C (HCV) infection |
| Denominator Description | Pts >= 18 Yrs w/ 2 Office Visits OR 1 Preventative Visit in 12 months |
| Numerator Description | HCV Infection Screening at Any Time |
| Exception Description | Medical or Pt Reason for not receiving screening for HCV |
| Exclusion Description | Diagnosis for Chronic Hepatitis C |
Pneumonia Vaccine
| Measure Description | Immunization - Pts >=65 and Who Had Pneumonia Vaccine |
| Denominator Description | Age >=65 years with Encounter in 12 Mos |
| Numerator Description | Pts with Pneumonia vaccination recorded |
| Exception Description | None |
| Exclusion Description | None |
Pneumothorax on Ventilators for NICU patients
| Measure Description | Pneumothorax on Ventilators for NICU patients |
| Denominator Description | Number of patients seen by neonatologist |
| Numerator Description | Number of patients on ventilators who develop pneumothorax |
| Exception Description | None |
| Exclusion Description | None |
Prenatal and Postpartum Care, 2025
Timeliness of Prenatal Care
| Measure Description | Timeliness of Prenatal Care |
| Denominator Description | Percentage of Live Birth between Oct 8, 2024 and Oct 7, 2025 |
| Numerator Description | Prenatal Care visit in 1st Trimester |
| Exception Description | Patients other than Female |
| Exclusion Description | Non-Live Births |
Postpartum Care
| Measure Description | Postpartum Care |
| Denominator Description | Percentage of Live Birth between Oct 8, 2024 and Oct 7, 2025 |
| Numerator Description | Postpartum Care Between 7-84 Days After Delivery |
| Exception Description | Patients other than Female |
| Exclusion Description | Non-Live Births |
Preventive Care & Screening: Tobacco Use: Screening & Cessation, 2025
(a) Tobacco Use: Screening
| Measure Description | (a) Tobacco Use: Screening |
| Denominator Description | Patients >=12 Yrs & >= 2 Visits or >=1 Prev Visit w/in 12 Months |
| Numerator Description | Pts Screened For Tobacco Use w/in 12 Months |
| Exception Description | None |
| Exclusion Description | Patients Who Are In Hospice Care |
(b)Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention for Tobacco Users
| Measure Description | (b) Tobacco Use: Cessation Intervention for Tobacco Users |
| Denominator Description | Pts >=12 Yrs & >= 2 Visits or >= 1 Preventative Visit w/in 12 Months & Tobacco User |
| Numerator Description | Pts Received Tobacco Cessation Intervention w/in 18 Months |
| Exception Description | None |
| Exclusion Description | Patients Who Are In Hospice Care |
Retained Foreign Body
| Measure Description | Retained Foreign Body |
| Denominator Description | Surgical Procedures-Retained Foreign Body within 12 Months |
| Numerator Description | Number of recorded incidents where a foreign body was retained in patient |
| Exception Description | None |
| Exclusion Description | None |
Screening for Depression and Follow-Up
Pts Screened for Depression w/in 12 Mos
| Measure Description | Pts Screened for Depression w/in 12 Mos |
| Denominator Description | Pts >= 12 Years |
| Numerator Description | Patients w/ Neg Screen OR Pos Screen w/in 12 mos |
| Exception Description | Patients with a Documented Reason for not Screening for Depression |
| Exclusion Description | DX Depression, Bipolar, Hospice |
Pts Positive for Depression w/in 12 Mos w/Follow-up
| Measure Description | Pts Positive for Depression w/in 12 Mos w/Follow-up |
| Denominator Description | Pts >= 12 Years w/Positive Depression Screen in 12 Mos |
| Numerator Description | Patients w/ Appropriate Follow-up |
| Exception Description | Patients with a Documented Reason for not Screening for Depression |
| Exclusion Description | DX Depression, Bipolar, Hospice |
Screening for Osteoporosis for Women
| Measure Description | Women Aged 65 - 85 who had central dual-energy X-ray absorptiometry(DXA) to check for osteoporosis |
| Denominator Description | Females 65-85 without a diagnosis of Osteoporosis |
| Numerator Description | Documented results of a central Dual-energy X-Ray Absorptiometry(DXA) |
| Exception Description | Patients other than Female |
| Exclusion Description | Hospice during Measurement Period |
Screening For Social Drivers Of Health
| Measure Description | Patients >=18 Years On Encounter, Screened For Food Insecurity, Housing Instability, Transportation Needs, Utility Difficulties, and Interpersonal Safety |
| Denominator Description | Patients >= 18 years at Encounter |
| Numerator Description | Screened For Social Drivers Health During MP |
| Exception Description | Patient Refused To Take Health Screening |
| Exclusion Description | None |
Skin Protection Counseling
| Measure Description | Percentage of patients >= 18 years counseled on skin cancer prevention in 12 mos |
| Denominator Description | Patients >=18 years w/ at least 1 encounter in 12 months |
| Numerator Description | Patients with Skin Cancer Prevention Documented in 12 months |
| Exception Description | None |
| Exclusion Description | Pts in Hospice |
Spirometry Test for COPD patients
| Measure Description | Pts >=18 Years with COPD Diagnosis Who Received Spirometry Test |
| Denominator Description | Patients Age >= 18 years with COPD Dx |
| Numerator Description | Received Spirometry Test |
| Exception Description | None |
| Exclusion Description | Hospice |
Statin Recommended at Discharge for Stroke Patients
| Measure Description | Statin Recommended at Discharge for Stroke Patients |
| Denominator Description | Number of stroke patients seen by neurologist |
| Numerator Description | Stroke pts who received statin recommendation by neurologist on discharge |
| Exception Description | None |
| Exclusion Description | None |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, 2025
| Measure Description | Pts w/ Clinical ASCVD Diagnosis Prescribed Statin Therapy |
| Denominator Description | Pts w/ ASCVD w/ >=1 Visit w/in 12 Mos |
| Numerator Description | Prescribed Statin Therapy |
| Exception Description | Contraindicated DX or Statin Intolerance or Hospice or Palliative Care |
| Exclusion Description | Pregnant/Breastfeeding or Rhabdomyolysis |
Well Child Visits (W15/W30)
Well-Child Visits in the First 15 Months
| Measure Description | Well-Child Visits in the First 15 Months |
| Denominator Description | Children who turn 15 months old during the measurement year |
| Numerator Description | Six or more well-child visits on or before the 15 month birthday |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Well-Child Visits for Age 15 Months–30 Months
| Measure Description | Well-Child Visits for Age 15 Months–30 Months |
| Denominator Description | Children who turn 30 months old during the measurement year |
| Numerator Description | Two or more well-child visits between the 15-30 month birthday |
| Exception Description | None |
| Exclusion Description | Patients in Hospice |
Wrong Site Surgery
| Measure Description | Wrong Site Surgery |
| Denominator Description | Surgical Procedures-Wrong Site within 12 Months |
| Numerator Description | Incidents where Surgery was Performed on Wrong Site |
| Exception Description | None |
| Exclusion Description | None |