REQUIRED: Submit a minimum of one (1) eCQM plus two additional measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.

• May elect to submit additional measures based on patient population / services offered.

• Not required to submit PC measures but may do so if they choose.

REQUIRED: Your hospital must submit a minimum of one (1) eCQM applicable to patient population/services from those listed below:

IP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient) (NEW)

OP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Outpatient) (NEW)

NOTE: If OP-ExRad is reported, one (1) self-selected quarter is required and will count as a complete measure / towards meeting the eCQM requirement

HH-PI (eCQM) Hospital Harm - Pressure Injury (NEW)

GMCS (eCQM) Global Malnutrition Composite Score

HH-HYPO (eCQM) Hospital Harm—Severe Hypoglycemia Measure

HH-HYPER (eCQM) Hospital Harm—Severe Hyperglycemia Measure

HH-ORAE (eCQM) Hospital Harm—Opioid Related Adverse Events

OP-40 (eCQM) ST-Segment Elevation Myocardial Infarction (STEMI)

NOTE: If OP-40 is reported, two (2) self-selected quarter are required and will count as a complete measure / towards meeting the eCQM requirement.

PC-01 (eCQM) Elective Delivery

PC-05 (eCQM) Exclusive Human Milk Feeding

PC-06 (eCQM) Unexpected Complications in Term Newborns

PC-07 (eCQM) Severe Obstetric Complications

Safe Use of Opioids (eCQM) Safe Use of Opioids - Concurrent Prescribing

STK-2 (eCQM) Discharged on Antithrombotic Therapy

STK-3 (eCQM) Anticoagulation Therapy Atrial Fibrillation/Flutter

STK-5 (eCQM) Antithrombotic Therapy by End of Hospital Day 2

VTE-1 (eCQM) Venous Thromboembolism Prophylaxis

VTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis

OPTIONAL Chart-abstracted measures (CAM); hospitals may elected to submit any of the below measures if they choose. NOTE: Any chart-abstracted measure(s) submitted the first quarter of the calendar year are required to be submitted for the remainder of the calendar year unless otherwise noted.

ED-1 (CAM) Median ED Arrival to ED Departure-Admit

ED-2 (CAM) Admit Decision Time to ED Departure-Admit

HBIPS-2 (CAM) Hours of Physical Restraint Use

HBIPS-3 (CAM) Hours of Seclusion Use

IMM-2 (CAM) Influenza Immunization

NOTE: IMM-2 is a seasonal measure; only 1Q and 4Q data are submitted

OP-18 (CAM) Median ED Arrival-ED Departure at Discharge

OP-23 (CAM) Head CT or MRI Scan Results-Stroke

PC-01 (CAM) Elective Delivery

PC-02 (CAM) Cesarean Birth

PC-05 (CAM) Exclusive Human Milk Feeding

PC-06 (CAM) Unexpected Complications in Term Newborns

SDOH-1 (CAM) Screening for Social Drivers of Health

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

SDOH-2 (CAM) Screen Positive Rate for Social Drivers of Health

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

SUB-2 (CAM) Alcohol Use Brief Intervention

SUB-3 (CAM) Alcohol & Drug Use Treatment at Discharge

TOB-3 (CAM) Tobacco Use Treatment at Discharge