1

Effective Clinical Care

Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

47

Communication and Care Coordination

Advance Care Plan

48

Effective Clinical Care

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

50

Person and Caregiver-Centered Experience and Outcomes

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

102

Efficiency and Cost Reduction

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

104

Effective Clinical Care

Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

110

Community / Population Health

Preventative Care and Screening: Influenza Immunization

111

Community / Population Health

Pneumococcal Vaccination Status for Older Adults

112

Effective Clinical Care

Breast Cancer Screening

113

Effective Clinical Care

Colorectal Cancer Screening

117

Effective Clinical Care

Diabetes: Eye Exam

119

Effective Clinical Care

Diabetes: Medical Attention for Nephropathy

128

Community / Population Health

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

130

Patient Safety

Documentation of Current Medications in the Medical Record

134

Community / Population Health

Preventive Care and Screening: Screening for Depression and Follow-up Plan

226

Community / Population Health

Preventive Care and Screening: Tobacco Use:  Screening and Cessation Intervention

236

Effective Clinical Care

Controlling High Blood Pressure

265

Communication and Care Coordination

Biopsy Follow-Up

317

Community / Population Health

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

318

Community / Population Health

Falls: Screening for Future Fall Risk

357

Effective Clinical Care

Surgical Site Infection (SSI)

358

Person and Caregiver-Centered Experience and Outcomes

Patient-Centered Surgical Risk Assessment & Communication

370

Effective Clinical Care

Depression Remission at Twelve Months

374

Communication & Care Coordination

Closing the Referral Loop: Receipt of Specialist Report

431

Community / Population Health

Preventive Care and Screening Unhealthy Alcohol Use: Screening & Brief Counseling

432

Patient Safety

Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

433

Patient Safety

Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

438

Effective Clinical Care

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

462

Effective Clinical Care

Bone density evaluation for patient with Prostate Cancer and receiving Androgen Deprivation Therapy

476

Person and Caregiver-Centered Experience and Outcomes

Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

481

Effective Clinical Care

Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer