Hospital and Critical Access Hospital (HAP/CAH) Accreditation

Topics Covered in this section:

Chart-abstracted Measures (CAM)
Electronic Clinical Quality Measure (eCQM)

CHART-ABSTRACTED MEASURES

Resource Title: American College of Emergency Physicians (ACEP), Emergency Department Crowding: High Impact Solutions Link: https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: American College of Emergency Physicians (ACEP), Emergency Department Crowding: High Impact Solutions

Link: https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: Emergency Department Quality Improvement: Transforming the Delivery of Care Link: https://www.healthcatalyst.com/insights/emergency-department-quality-improvement-transforming-delivery-care

Resource Title: Emergency Department Quality Improvement: Transforming the Delivery of Care

Link: https://www.healthcatalyst.com/insights/emergency-department-quality-improvement-transforming-delivery-care

Resource Title: National Center for Health Statistics National Hospital Ambulatory Survey: 2020 Emergency Department Summary Tables

Link: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcs-ed-web-tables-508.pdf

Resource Title: APNA Standards of Practice: Seclusion and Restraint Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/

Resource Title: APNA Standards of Practice: Seclusion and Restraint Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/

Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint Link: http://apapsy.ch/S-R

Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint Link: http://apapsy.ch/S-R

Resource Title: CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2024-25 Link: https://www.cdc.gov/flu/hcp/acip/index.html

Resource Title: CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2024-25

Link: https://www.cdc.gov/flu/hcp/acip/index.html

Resource Title: National Adult and Influenza Immunization Summit: Influenza Vaccination Resources

Link: https://www.izsummitpartners.org/influenza-vaccination-resources/

Resource Title: AHRQ Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: AHRQ Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: American College of Emergency Physicians Approaching Full Capacity in the Emergency Department

Link: https://www.acep.org/siteassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: American Heart Association Target: Stroke Direct to CT/MRI Protocol Link: https://www.heart.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-ii/ts_directtoct_ucm_470723.pdf?la=en&hash=D8E20DFC9A703E20B388E4AAFC204E98ACDF4D53

Resource Title: American Heart Association Target: Stroke Direct to CT/MRI Protocol Link: https://www.heart.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-ii/ts_directtoct_ucm_470723.pdf?la=en&hash=D8E20DFC9A703E20B388E4AAFC204E98ACDF4D53

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://digitalassets.jointcommission.org/api/public/content/6f9cc62829194a13a8619074a95c8b1f?v=1a88db59

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit

Link: http://www.usbreastfeeding.org/

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits

Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality

Link: https://www.cdc.gov/maternal-infant-health/infant-mortality/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

Resource Title: Social Drivers of Health and Health-Related Social Needs Link: https://www.cms.gov/priorities-innovation-key-concepts-social-drivers-health-health-related-social-needs

Resource Title: Social Drivers of Health and Health-Related Social Needs Link: https://www.cms.gov/priorities-innovation-key-concepts-social-drivers-health-health-related-social-needs

Resource Title: Social Drivers of Health and Health-Related Social Needs Link: https://www.cms.gov/priorities-innovation-key-concepts-social-drivers-health-health-related-social-needs

Resource Title: Social Drivers of Health and Health-Related Social Needs Link: https://www.cms.gov/priorities-innovation-key-concepts-social-drivers-health-health-related-social-needs

Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment Link: https://www.samhsa.gov/sbirt

Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment Link: https://www.samhsa.gov/sbirt

Resource Title: NIAAA- National Institute of Alcohol Abuse and Alcoholism Link: https://alcoholtreatment.niaaa.nih.gov/healthcare-professionals

Resource Title: NIAAA- National Institute of Alcohol Abuse and Alcoholism

Link: https://alcoholtreatment.niaaa.nih.gov/healthcare-professionals

Resource Title: SAMHSA: Substance Abuse and Mental Health Services Administration

Link: https://www.samhsa.gov/substance-use/treatment/resources/provider-support

Resource Title: American Lung Association Link: https://www.lung.org/policy-advocacy/tobacco/cessation/technical-assistance/cessation-toolkits/behavioral-health/equipping-behavioral-health-care-teams

Resource Title: American Lung Association Link: https://www.lung.org/policy-advocacy/tobacco/cessation/technical-assistance/cessation-toolkits/behavioral-health/equipping-behavioral-health-care-teams

Electronic Clinical Quality Measures (eCQMs)

Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources Link: https://www.cdrnet.org/GMCS

Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources Link: https://www.cdrnet.org/GMCS

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: Society of Hospital Medicine: Opioid Safety Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/

Resource Title: Society of Hospital Medicine: Opioid Safety Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/

Resource Title: AHRQ: Preventing Pressure Ulcers in Hospitals Link: https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7.html

Resource Title: AHRQ: Preventing Pressure Ulcers in Hospitals Link: https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7.html

Resource Title: AHA/ASA Journals: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Link: https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6

Resource Title: AHA/ASA Journals: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Link: https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6

Resource Title: AHA/ASA Journals: Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.120.009179

Resource Title: AHA/ASA Journals: Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.120.009179

Resource Title: American College of Radiology- Radiation Safety Link: https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/radiology-safety/radiation-safety

Resource Title: American College of Radiology- Radiation Safety Link: https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/radiology-safety/radiation-safety

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team Link: https://digitalassets.jointcommission.org/api/public/content/6f9cc62829194a13a8619074a95c8b1f?v=1a88db59

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team Link: https://digitalassets.jointcommission.org/api/public/content/6f9cc62829194a13a8619074a95c8b1f?v=1a88db59

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit Link: https://www.usbreastfeeding.org/publications.html

Resource Title: The United States Breastfeeding Committee toolkit Link: https://www.usbreastfeeding.org/publications.html

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality Link: https://www.cdc.gov/maternal-infant-health/infant-mortality/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality Link: https://www.cdc.gov/maternal-infant-health/infant-mortality/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

Resource Title: American Hospital Association Maternal and Child Health Tools and Resources Link: https://www.aha.org/maternal-child-health-tools-resources

Resource Title: American Hospital Association Maternal and Child Health Tools and Resources Link: https://www.aha.org/maternal-child-health-tools-resources

Resource Title: Alliance for Innovation on Maternal Health Link: https://saferbirth.org/

Resource Title: Alliance for Innovation on Maternal Health Link: https://saferbirth.org/

Resource Title: Society for Maternal-Fetal Medicine Special Statement

Link: https://www.ajog.org/article/S0002-9378(21)01108-X/fulltext

Resource Title: CMQCC Hypertension Toolkit

Link: https://www.cmqcc.org/toolkits-quality-improvement/hypertensive-disorders-pregnancy

Resource Title: 2021 Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack from the American Heart Association/American Stroke Association Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

Resource Title: 2021 Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack from the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

Resource Title: 2026 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/10.1161/STR.0000000000000513

Resource Title: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack From the American Heart Association/American Stroke Association Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

Resource Title: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack From the American Heart Association/American Stroke Association Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

Resource Title: 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association Link: https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000158

Resource Title: 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000158

Resource Title: 2026 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/10.1161/STR.0000000000000513

Resource Title: StatPearls Deep Venous Thrombosis Prophylaxis, May 7, 2023 Link: https://www.ncbi.nlm.nih.gov/books/NBK534865/#:~:text=DVT%20prophylaxis%20can%20be%20primary,the%20treatment%20of%20subclinical%20DVT

Resource Title: StatPearls Deep Venous Thrombosis Prophylaxis, May 7, 2023

Link: https://www.ncbi.nlm.nih.gov/books/NBK534865/#:~:text=DVT%20prophylaxis%20can%20be%20primary,the%20treatment%20of%20subclinical%20DVT

Resource Title: American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients

Link: https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines/venous-thromboembolism-guidelines/prophylaxis-for-medical-patients

Resource Title: StatPearls Deep Venous Thrombosis Prophylaxis, May 7, 2023 Link: https://www.ncbi.nlm.nih.gov/books/NBK534865/#:~:text=DVT%20prophylaxis%20can%20be%20primary,the%20treatment%20of%20subclinical%20DVT