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The Leapfrog Group offers the only national, independent datasets focused exclusively on patient safety, quality of care, and transparency at the facility level. Leapfrog data is self-reported by facilities or collected via third-party sources (such as CMS, the CDC, applicable national registries, etc.) and then vetted through a rigorous five-step verification process.
An annual survey providing in-depth insights into quality and safety standards for hospitals.
An annual survey evaluating safety and quality for ambulatory surgery centers, bringing transparency to a growing sector in clinical care.
Assigns letter grades (A through F) to nearly 3,000 hospitals nationwide. Released biannually, the Safety Grade assesses hospitals on their ability to prevent errors, injuries, and infections.
Leapfrog’s data offers comprehensive, timely insights into how hospitals and ambulatory surgery centers deliver care. Whether you're a payer, solution provider, consultant, researcher, or startup, licensing Leapfrog’s data can unlock opportunities to benchmark clinical performance, inform network strategy, identify prospective clients, or drive better health outcomes.
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Leapfrog Hospital Survey
Leapfrog ASC Survey
Leapfrog Hospital Safety GradePatient Rights and Ethics
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Billing Ethics | Billing Ethics measures the implementation of transparent billing practices
including providing patients with complete billing information, access to
representatives that can quickly resolve billing issues, and not taking harmful
legal action against patients for late or unpaid bills. | 2025 | 4 | |
Health Care Equity | Health Equity measures the implementation of best practices related to
identifying and eliminating differences in processes or outcomes for patients of
different races and ethnicities, and patients who speak different languages. | 2025 | 2 | |
Informed Consent | Informed Consent measures the implementation of a robust informed consent
process to ensure patients are fully aware of risks and alternatives prior to
surgery. | 2025 | 3 | |
Response to “Never Events” | Never Events measures the implementation of a robust policy following an adverse
event (e.g., “never event”), including apologizing to the patient and waiving
costs associated with the event. | 2025 | 19 | |
Billing Ethics
Billing Ethics measures the implementation of transparent billing practices
including providing patients with complete billing information, access to
representatives that can quickly resolve billing issues, and not taking harmful
legal action against patients for late or unpaid bills.
Reporting Period:2025
Years Available:4
Data Sets:
Health Care Equity
Health Equity measures the implementation of best practices related to
identifying and eliminating differences in processes or outcomes for patients of
different races and ethnicities, and patients who speak different languages.
Reporting Period:2025
Years Available:2
Data Sets:
Informed Consent
Informed Consent measures the implementation of a robust informed consent
process to ensure patients are fully aware of risks and alternatives prior to
surgery.
Reporting Period:2025
Years Available:3
Data Sets:
Response to “Never Events”
Never Events measures the implementation of a robust policy following an adverse
event (e.g., “never event”), including apologizing to the patient and waiving
costs associated with the event.
Reporting Period:2025
Years Available:19
Data Sets:
Patient Safety Practices
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Hospital Safety Grades | Hospital Safety Grades measure a hospital’s track record in keeping patients
safety from medical errors using up to 30 national performance measures. | Multiple | 14 | |
NQF Safe Practice #1 – Culture of Safety Leadership Structures and Systems | NQF Safe Practice #1 measures the implementation of evidence-based practices for
Culture of Safety Leadership Structures and Systems endorsed by the National
Quality Forum, which reduce adverse events. | 2025 | 21 | |
NQF Safe Practice #2 – Culture Measurement, Feedback, and Intervention | NQF Safe Practice #2 measures the implementation of evidence-based practices for
Culture Measurement, Feedback, and Intervention endorsed by the National Quality
Forum, which reduce adverse events. | 2025 | 21 | |
NQF Safe Practice #4 – Identification and Mitigation of Risks and Hazards | NQF Safe Practice #4 measures the implementation of evidence-based practices for
Identification and Mitigation of Risks and Hazards endorsed by the National
Quality Forum, which reduce adverse events. | 2025 | 21 | |
Total Nursing Care Hours per Patient Day | Total Nursing Hours per Patient Day measures the total number of nursing care
hours provided by registered nurses, licensed practical nurses, and unlicensed
assistive personnel per patient day in adult and pediatric medical, surgical, or
med-surg units. | CY2024 | 3 | |
RN Hours per Patient Day | RN Hours per Patient Day measures the total number of nursing care hours
provided by registered nurses per patient day in adult and pediatric medical,
surgical, or med-surg units. | CY2024 | 3 | |
Nursing Skill Mix | Nursing Skill Mix measures the percentage registered nursing (RN) hours out of
the total nursing hours per patient day in adult and pediatric medical,
surgical, or med-surg units. | CY2024 | 3 | |
Percentage of RNs who are BSN-Prepared | Percentage of RNs who are BSN-Prepared measures the percentage of registered
nurses with a bachelor’s degree in nursing. | 2025 | 3 | |
Hand Hygiene | Hand Hygiene measures adherence to best practices for Hand Hygiene identified by
Leapfrog's National Hand Hygiene Expert Panel and adopted in part from the World
Health Organization’s Hand Hygiene Self-Assessment Framework. | 2025 | 6 | |
Hospital Safety Grades
Hospital Safety Grades measure a hospital’s track record in keeping patients
safety from medical errors using up to 30 national performance measures.
Reporting Period:Multiple
Years Available:14
Data Sets:
NQF Safe Practice #1 – Culture of Safety Leadership Structures and Systems
NQF Safe Practice #1 measures the implementation of evidence-based practices for
Culture of Safety Leadership Structures and Systems endorsed by the National
Quality Forum, which reduce adverse events.
Reporting Period:2025
Years Available:21
Data Sets:
NQF Safe Practice #2 – Culture Measurement, Feedback, and Intervention
NQF Safe Practice #2 measures the implementation of evidence-based practices for
Culture Measurement, Feedback, and Intervention endorsed by the National Quality
Forum, which reduce adverse events.
Reporting Period:2025
Years Available:21
Data Sets:
NQF Safe Practice #4 – Identification and Mitigation of Risks and Hazards
NQF Safe Practice #4 measures the implementation of evidence-based practices for
Identification and Mitigation of Risks and Hazards endorsed by the National
Quality Forum, which reduce adverse events.
Reporting Period:2025
Years Available:21
Data Sets:
Total Nursing Care Hours per Patient Day
Total Nursing Hours per Patient Day measures the total number of nursing care
hours provided by registered nurses, licensed practical nurses, and unlicensed
assistive personnel per patient day in adult and pediatric medical, surgical, or
med-surg units.
Reporting Period:CY2024
Years Available:3
Data Sets:
RN Hours per Patient Day
RN Hours per Patient Day measures the total number of nursing care hours
provided by registered nurses per patient day in adult and pediatric medical,
surgical, or med-surg units.
Reporting Period:CY2024
Years Available:3
Data Sets:
Nursing Skill Mix
Nursing Skill Mix measures the percentage registered nursing (RN) hours out of
the total nursing hours per patient day in adult and pediatric medical,
surgical, or med-surg units.
Reporting Period:CY2024
Years Available:3
Data Sets:
Percentage of RNs who are BSN-Prepared
Percentage of RNs who are BSN-Prepared measures the percentage of registered
nurses with a bachelor’s degree in nursing.
Reporting Period:2025
Years Available:3
Data Sets:
Hand Hygiene
Hand Hygiene measures adherence to best practices for Hand Hygiene identified by
Leapfrog's National Hand Hygiene Expert Panel and adopted in part from the World
Health Organization’s Hand Hygiene Self-Assessment Framework.
Reporting Period:2025
Years Available:6
Data Sets:
Medication Safety
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Computerized Prescriber Order Entry for Inpatient Medications | Computerized Physician Order Entry (CPOE) measures the use and the effectiveness
of CPOE systems that include electronic clinical decision support, which reduces
adverse drug events. | 2025 | 16 | |
Bar Code Medication Administration (BCMA) for Inpatient Medications | Bar Code Medication Administration (BCMA) measures the use of BCMA in inpatient
units and pre-operative and post anesthesia care units to reduce medication
administration errors. | 2025 | 10 | |
Medication Reconciliation | Medication Reconciliation measures the rate of unintentional medication
discrepancies resulting from the medication reconciliation process. | 2025 | 8 | |
Medication Documentation During Outpatient Surgery | Medication Documentation During Outpatient Surgery measures the percentage of
same-day surgery patients who had all medications and allergies documented to
reduce errors and adverse drug events. | CY2024 | 6 | — |
Computerized Prescriber Order Entry for Inpatient Medications
Computerized Physician Order Entry (CPOE) measures the use and the effectiveness
of CPOE systems that include electronic clinical decision support, which reduces
adverse drug events.
Reporting Period:2025
Years Available:16
Data Sets:
Bar Code Medication Administration (BCMA) for Inpatient Medications
Bar Code Medication Administration (BCMA) measures the use of BCMA in inpatient
units and pre-operative and post anesthesia care units to reduce medication
administration errors.
Reporting Period:2025
Years Available:10
Data Sets:
Medication Reconciliation
Medication Reconciliation measures the rate of unintentional medication
discrepancies resulting from the medication reconciliation process.
Reporting Period:2025
Years Available:8
Data Sets:
Medication Documentation During Outpatient Surgery
Medication Documentation During Outpatient Surgery measures the percentage of
same-day surgery patients who had all medications and allergies documented to
reduce errors and adverse drug events.
Reporting Period:CY2024
Years Available:6
Data Sets:—
Patient Experience
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Communication with Nurses (CMS H-COMP 1) | Communication with Nurses measures patient experience with nurse communication
during a hospitalization. | 01/01/2023 - 12/31/2023 | 14 | |
Communication with Doctors (CMS H-COMP 2) | Communication with Doctors measures patient experience with doctor communication
during a hospitalization. | 01/01/2023 - 12/31/2023 | 14 | |
Staff Responsiveness (CMS H-COMP 3) | Staff Responsiveness measures patient experience with staff responsiveness
during a hospitalization. | 01/01/2023 - 12/31/2023 | 14 | |
Communication about Medicines (CMS H-COMP 5) | Communication about Medicines measures patient experience with receiving clear
communication about their medicines during a hospitalization. | 01/01/2023 - 12/31/2023 | 14 | |
Discharge Information (CMS H-COMP 6) | Discharge information measures patient experience with receiving clear discharge
information during a hospitalization. | 01/01/2023 - 12/31/2023 | 14 | |
Outpatient and Ambulatory Surgery Patient Experience (OAS CAHPS) | OAS CAHPS measures patient experience during a same-day surgery. | 2025 | 6 | |
Pediatric Patient Experience (CAHPS Child Hospital Survey) | Pediatric Patient Experience measures patient and family experience during a
hospitalization. | 2025 | 8 | |
Communication with Nurses (CMS H-COMP 1)
Communication with Nurses measures patient experience with nurse communication
during a hospitalization.
Reporting Period:01/01/2023 - 12/31/2023
Years Available:14
Data Sets:
Communication with Doctors (CMS H-COMP 2)
Communication with Doctors measures patient experience with doctor communication
during a hospitalization.
Reporting Period:01/01/2023 - 12/31/2023
Years Available:14
Data Sets:
Staff Responsiveness (CMS H-COMP 3)
Staff Responsiveness measures patient experience with staff responsiveness
during a hospitalization.
Reporting Period:01/01/2023 - 12/31/2023
Years Available:14
Data Sets:
Communication about Medicines (CMS H-COMP 5)
Communication about Medicines measures patient experience with receiving clear
communication about their medicines during a hospitalization.
Reporting Period:01/01/2023 - 12/31/2023
Years Available:14
Data Sets:
Discharge Information (CMS H-COMP 6)
Discharge information measures patient experience with receiving clear discharge
information during a hospitalization.
Reporting Period:01/01/2023 - 12/31/2023
Years Available:14
Data Sets:
Outpatient and Ambulatory Surgery Patient Experience (OAS CAHPS)
OAS CAHPS measures patient experience during a same-day surgery.
Reporting Period:2025
Years Available:6
Data Sets:
Pediatric Patient Experience (CAHPS Child Hospital Survey)
Pediatric Patient Experience measures patient and family experience during a
hospitalization.
Reporting Period:2025
Years Available:8
Data Sets:
Healthcare Associated Infections
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Central-line Associated Blood Stream Infections (CLABSI) in ICUs and select wards | Central-Line Associated Blood Stream Infections (CLABSI) in ICUs and Select
Wards measures the actual number of infections compared to an expected number of
infections (which is based on national benchmarks), resulting in a standardized
infection ratio (SIR). | CY2024 | 9 | |
Catheter-associated Urinary Tract Infections (CAUTI) in ICUs and select wards | Catheter-Associated Urinary Tract Infections (CAUTI) in ICUs and Select Wards
measures the actual number of infections to an expected number of infections
(which is based on national benchmarks), resulting in a standardized infection
ratio (SIR). | CY2024 | 9 | |
Surgical Site Infections from Colon Surgery (SSI: Colon) | Surgical Site Infections from Colon Surgery (SSI: Colon) measures the actual
number of infections to an expected number of infections (which is based on
national benchmarks), resulting in a standardized infection ratio (SIR). | CY2024 | 9 | |
Facility-wide Inpatient Methicillin-resistant Staphylococcus aureus (MRSA) Blood Laboratory-identified Events | Facility-Wide inpatient Methicillin-Resistant Staphylococcus Aureus (MRSA) Blood
Laboratory-Identified Events measures the actual number of infections to an
expected number of infections (which is based on national benchmarks), resulting
in a standardized infection ratio (SIR). | CY2024 | 9 | |
Facility-wide Inpatient Clostridium difficile (CDI) Laboratory-identified Events | Facility-Wide Inpatient Clostridium Difficile Infection (C. Diff.)
Laboratory-Identified Events measures the actual number of infections to an
expected number of infections (which is based on national benchmarks), resulting
in a standardized infection ratio (SIR). | CY2024 | 9 | |
Surgical Site Infection Surveillance in Ambulatory Surgery Centers | Surgical Site Infection Surveillance measures CDC guidance regarding surgical
site infection surveillance following breast surgery, laminectomy,
herniorrhaphy, and knee prosthesis. | 2025 | 6 | |
Central-line Associated Blood Stream Infections (CLABSI) in ICUs and select wards
Central-Line Associated Blood Stream Infections (CLABSI) in ICUs and Select
Wards measures the actual number of infections compared to an expected number of
infections (which is based on national benchmarks), resulting in a standardized
infection ratio (SIR).
Reporting Period:CY2024
Years Available:9
Data Sets:
Catheter-associated Urinary Tract Infections (CAUTI) in ICUs and select wards
Catheter-Associated Urinary Tract Infections (CAUTI) in ICUs and Select Wards
measures the actual number of infections to an expected number of infections
(which is based on national benchmarks), resulting in a standardized infection
ratio (SIR).
Reporting Period:CY2024
Years Available:9
Data Sets:
Surgical Site Infections from Colon Surgery (SSI: Colon)
Surgical Site Infections from Colon Surgery (SSI: Colon) measures the actual
number of infections to an expected number of infections (which is based on
national benchmarks), resulting in a standardized infection ratio (SIR).
Reporting Period:CY2024
Years Available:9
Data Sets:
Facility-wide Inpatient Methicillin-resistant Staphylococcus aureus (MRSA) Blood Laboratory-identified Events
Facility-Wide inpatient Methicillin-Resistant Staphylococcus Aureus (MRSA) Blood
Laboratory-Identified Events measures the actual number of infections to an
expected number of infections (which is based on national benchmarks), resulting
in a standardized infection ratio (SIR).
Reporting Period:CY2024
Years Available:9
Data Sets:
Facility-wide Inpatient Clostridium difficile (CDI) Laboratory-identified Events
Facility-Wide Inpatient Clostridium Difficile Infection (C. Diff.)
Laboratory-Identified Events measures the actual number of infections to an
expected number of infections (which is based on national benchmarks), resulting
in a standardized infection ratio (SIR).
Reporting Period:CY2024
Years Available:9
Data Sets:
Surgical Site Infection Surveillance in Ambulatory Surgery Centers
Surgical Site Infection Surveillance measures CDC guidance regarding surgical
site infection surveillance following breast surgery, laminectomy,
herniorrhaphy, and knee prosthesis.
Reporting Period:2025
Years Available:6
Data Sets:
Critical Care
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Adult ICU Physician Staffing (IPS) | Adult ICU Physician Staffing (IPS) measures the use of critical care-certified
physicians to manage/co-manage adult critical care patients in medical and/or
surgical ICUs and neuro ICUs, which significantly reduces mortality. | 2025 | 24 | |
Pediatric ICU Physician Staffing (IPS) | Pediatric ICU Physician Staffing (IPS) measures the use of critical
care-certified physicians to manage/co-manage critical care patients in
pediatric medical and/or surgical ICUs and neuro ICUs, which significantly
reduces mortality. | 2025 | 1 | |
Adult ICU Physician Staffing (IPS)
Adult ICU Physician Staffing (IPS) measures the use of critical care-certified
physicians to manage/co-manage adult critical care patients in medical and/or
surgical ICUs and neuro ICUs, which significantly reduces mortality.
Reporting Period:2025
Years Available:24
Data Sets:
Pediatric ICU Physician Staffing (IPS)
Pediatric ICU Physician Staffing (IPS) measures the use of critical
care-certified physicians to manage/co-manage critical care patients in
pediatric medical and/or surgical ICUs and neuro ICUs, which significantly
reduces mortality.
Reporting Period:2025
Years Available:1
Data Sets:
Maternity Care
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Volume of Deliveries | Total number of newborn deliveries. | CY2024 | 8 | |
Midwives | Patients have access to certified midwives for labor and delivery. | 2025 | 3 | |
Doulas | Patients can bring their own doula for support during labor and delivery. | 2025 | 3 | |
Lactation Services | Patients have access to lactation consultants on an inpatient and/or outpatient
basis. | 2025 | 3 | |
Vaginal Deliveries after Cesarean Section | Patients have access to a vaginal delivery after a previous cesarean section. | 2025 | 3 | |
Postpartum tubal ligation during the labor and delivery admission | Patients have access to tubal ligation in combination with cesarean section or
shortly after vaginal birth. | 2025 | 3 | |
Early Elective Deliveries Policy | Early Elective Deliveries Policy measures whether hospitals have a policy in
place to prevent early elective deliveries, defined as planned births before 39
weeks of gestation. | 2025 | 17 | |
Cesarean Birth (PC-02) | Cesarean Birth measures the C-section rate among first-time mothers delivering a
single, full-term newborn in the vertex position, which can carry risks to both
babies and mothers. | CY2024 | 11 | |
Episiotomy | Episiotomy measures the episiotomy rate during vaginal deliveries, which can
cause long-term complications among mothers. | CY2024 | 14 | |
Newborn Bilirubin Screening Prior to Discharge | Newborn Bilirubin Screening Prior to Discharge measures the newborn screening
rate for jaundice prior to discharge to reduce the risk of serious complications
such as brain damage. | CY2024 | 17 | |
Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery | Appropriate DVT Prophylaxis measures the rate of pneumatic compression device
placement prior to a C-section to prevent blood clots. | CY2024 | 17 | |
Delivery of Very Low Birth-Weight Babies | Delivery of Very Low Birth-Weight Babies measures the volume of or outcomes from
very low-birth-weight deliveries. | CY2023 | 18 | |
Volume of Deliveries
Total number of newborn deliveries.
Reporting Period:CY2024
Years Available:8
Data Sets:
Midwives
Patients have access to certified midwives for labor and delivery.
Reporting Period:2025
Years Available:3
Data Sets:
Doulas
Patients can bring their own doula for support during labor and delivery.
Reporting Period:2025
Years Available:3
Data Sets:
Lactation Services
Patients have access to lactation consultants on an inpatient and/or outpatient
basis.
Reporting Period:2025
Years Available:3
Data Sets:
Vaginal Deliveries after Cesarean Section
Patients have access to a vaginal delivery after a previous cesarean section.
Reporting Period:2025
Years Available:3
Data Sets:
Postpartum tubal ligation during the labor and delivery admission
Patients have access to tubal ligation in combination with cesarean section or
shortly after vaginal birth.
Reporting Period:2025
Years Available:3
Data Sets:
Early Elective Deliveries Policy
Early Elective Deliveries Policy measures whether hospitals have a policy in
place to prevent early elective deliveries, defined as planned births before 39
weeks of gestation.
Reporting Period:2025
Years Available:17
Data Sets:
Cesarean Birth (PC-02)
Cesarean Birth measures the C-section rate among first-time mothers delivering a
single, full-term newborn in the vertex position, which can carry risks to both
babies and mothers.
Reporting Period:CY2024
Years Available:11
Data Sets:
Episiotomy
Episiotomy measures the episiotomy rate during vaginal deliveries, which can
cause long-term complications among mothers.
Reporting Period:CY2024
Years Available:14
Data Sets:
Newborn Bilirubin Screening Prior to Discharge
Newborn Bilirubin Screening Prior to Discharge measures the newborn screening
rate for jaundice prior to discharge to reduce the risk of serious complications
such as brain damage.
Reporting Period:CY2024
Years Available:17
Data Sets:
Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery
Appropriate DVT Prophylaxis measures the rate of pneumatic compression device
placement prior to a C-section to prevent blood clots.
Reporting Period:CY2024
Years Available:17
Data Sets:
Delivery of Very Low Birth-Weight Babies
Delivery of Very Low Birth-Weight Babies measures the volume of or outcomes from
very low-birth-weight deliveries.
Reporting Period:CY2023
Years Available:18
Data Sets:
Pediatric Care
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Pediatric Patient Experience (CAHPS Child Hospital Survey) | Pediatric Patient Experience measures patient and family experience during a
hospitalization. | 2025 | 8 | |
Radiation Dose for Abdomen/Pelvis CTs | Pediatric Computed Tomography (CT) Radiation Dose for Abdomen/Pelvis Scans
measures radiation doses for routine pediatric abdomen/pelvis scans compared to
national benchmarks. | CY2024 | 8 | |
Radiation Dose for Head CTs | Pediatric Computed Tomography (CT) Radiation Dose for Head Scans measures
radiation doses for routine pediatric head scans compared to national
benchmarks. | CY2024 | 8 | |
Pediatric ICU Physician Staffing (IPS) | Pediatric ICU Physician Staffing (IPS) measures the use of critical
care-certified physicians to manage/co-manage critical care patients in
pediatric medical and/or surgical ICUs and neuro ICUs, which significantly
reduces mortality. | 2025 | 1 | |
Norwood Procedure (Congenital Heart Surgery) | Congenital Heart Surgery measures the annual volume of procedures and whether
surgeons are required to perform a minimum number of procedures to maintain
their privileges. | CY2024 | 5 | |
Pediatric Patient Experience (CAHPS Child Hospital Survey)
Pediatric Patient Experience measures patient and family experience during a
hospitalization.
Reporting Period:2025
Years Available:8
Data Sets:
Radiation Dose for Abdomen/Pelvis CTs
Pediatric Computed Tomography (CT) Radiation Dose for Abdomen/Pelvis Scans
measures radiation doses for routine pediatric abdomen/pelvis scans compared to
national benchmarks.
Reporting Period:CY2024
Years Available:8
Data Sets:
Radiation Dose for Head CTs
Pediatric Computed Tomography (CT) Radiation Dose for Head Scans measures
radiation doses for routine pediatric head scans compared to national
benchmarks.
Reporting Period:CY2024
Years Available:8
Data Sets:
Pediatric ICU Physician Staffing (IPS)
Pediatric ICU Physician Staffing (IPS) measures the use of critical
care-certified physicians to manage/co-manage critical care patients in
pediatric medical and/or surgical ICUs and neuro ICUs, which significantly
reduces mortality.
Reporting Period:2025
Years Available:1
Data Sets:
Norwood Procedure (Congenital Heart Surgery)
Congenital Heart Surgery measures the annual volume of procedures and whether
surgeons are required to perform a minimum number of procedures to maintain
their privileges.
Reporting Period:CY2024
Years Available:5
Data Sets:
Inpatient Surgery
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Carotid Endarterectomy Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Mitral Valve Repair and Replacement Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. Includes outcomes from a
national registry. | CY2024 | 8 | |
Open Aortic Procedures Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Bariatric Surgery for Weight Loss Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Lung Resection for Cancer Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Esophageal Resection for Cancer Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Pancreatic Resection for Cancer Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Rectal Cancer Surgery Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Norwood Procedure (Congenital Heart Surgery) | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 5 | |
Total Hip Replacement Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 5 | |
Total Knee Replacement Hospital and Surgeon Volume | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 5 | |
Implementation of a Safe Surgery Checklist - Inpatient Surgery | Safe Surgery Checklist for Complex Surgery measures the implementation of a safe
surgical checklist for every inpatient procedure to reduce errors via an annual
audit. | 2025 | 4 | |
Carotid Endarterectomy Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Mitral Valve Repair and Replacement Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. Includes outcomes from a
national registry.
Reporting Period:CY2024
Years Available:8
Data Sets:
Open Aortic Procedures Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Bariatric Surgery for Weight Loss Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Lung Resection for Cancer Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Esophageal Resection for Cancer Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Pancreatic Resection for Cancer Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Rectal Cancer Surgery Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Norwood Procedure (Congenital Heart Surgery)
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:5
Data Sets:
Total Hip Replacement Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:5
Data Sets:
Total Knee Replacement Hospital and Surgeon Volume
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:5
Data Sets:
Implementation of a Safe Surgery Checklist - Inpatient Surgery
Safe Surgery Checklist for Complex Surgery measures the implementation of a safe
surgical checklist for every inpatient procedure to reduce errors via an annual
audit.
Reporting Period:2025
Years Available:4
Data Sets:
Outpatient Surgery
| Measure | Measure Description | Reporting Period | Years Data Available | Data Sets |
|---|---|---|---|---|
Medical, Surgical, and Clinical Staff – Adult Patients | Medical, Surgical, and Clinical Staff measures the presence of staff trained in
life-saving skills while adult patients are present in the facility. | 2025 | 6 | |
Medical, Surgical, and Clinical Staff – Pediatric Patients | Medical, Surgical, and Clinical Staff measures the presence of staff trained in
life-saving skills while pediatric patients are present in the facility. | None | 6 | — |
Facility and Surgeon Volume for
Bariatric Surgery for Weight Loss,
Total Hip Replacement,
Total Knee Replacement | Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes. | CY2024 | 8 | |
Gastroenterology Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
General Surgery Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
Ophthalmology Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
Orthopedic Adult Procedure Volume | Total volume of procedures. | CY2024 | 5 | |
Otolaryngology Adult Procedure Volume | Total volume of procedures. | CY2024 | 5 | |
Urology Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
Neurological Surgery Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
Obstetrics and Gynecology Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
Plastic and Reconstructive Surgery Adult Procedure Volume | Total volume of procedures. | CY2024 | 6 | |
General Surgery Pediatric Procedure Volume | Total volume of procedures | CY2024 | 6 | |
Ophthalmology Pediatric Procedure Volume | Total volume of procedures | CY2024 | 6 | |
Orthopedic Pediatric Procedure Volume | Total volume of procedures | CY2024 | 5 | |
Otolaryngology Pediatric Procedure Volume | Total volume of procedures | CY2024 | 5 | |
Patient Burns (CMS ASC-1) | Patient Burns measures the percentage of patients who experience a burn prior to
discharge from a surgery center. | 01/01/2023 – 12/31/2023 | 1 | |
Patient Falls (CMS ASC-2) | Patient Falls measures the percentage of patients who experience a fall in a
surgery center. | 01/01/2023 – 12/31/2023 | 1 | |
Wrong Site, Side, Patient, Procedure, or Implant (CMS ASC-3) | Wrong Site, Side, Patient, Procedure, or Implant measures the percentage of
patients who experience a wrong site, side, patient, procedure, or implant. | 01/01/2023 – 12/31/2023 | 1 | |
Patient Transfers or Admissions to a Hospital (CMS ASC-4) | Patient Transfers or Admissions to a Hospital measures the percentage of
patients who are transferred or admitted to a hospital upon discharge from a
surgery center. | 01/01/2023 – 12/31/2023 | 1 | |
Unplanned Hospital Visit after Outpatient Colonoscopy (CMS ASC-12; CMS OP-32) | Unplanned Hospital Visit after Outpatient Colonoscopy measures the rate of
unplanned hospital visits after outpatient colonoscopy that is lower than most
facilities. | 01/01/2021 – 12/31/2023 | 4 | |
Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures (CMS ASC-17) | Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures measures
the rate of unplanned hospital visits following an orthopedic surgery. | 01/01/2022 – 12/31/2023 | 3 | |
Hospital Visits After Urology Ambulatory Surgical Center Procedures (CMS ASC-18) | Hospital Visits After Urology Ambulatory Surgical Center Procedures measures the
rate of unplanned hospital visits after urology surgery. | 01/01/2022 – 12/31/2023 | 3 | |
Implementation of a Safe Surgery Checklist – Outpatient Surgery | Safe Surgery Checklist for Complex Surgery measures the implementation of a safe
surgical checklist for every inpatient procedure to reduce errors via an annual
audit. | 2025 | 6 | |
Medical, Surgical, and Clinical Staff – Adult Patients
Medical, Surgical, and Clinical Staff measures the presence of staff trained in
life-saving skills while adult patients are present in the facility.
Reporting Period:2025
Years Available:6
Data Sets:
Medical, Surgical, and Clinical Staff – Pediatric Patients
Medical, Surgical, and Clinical Staff measures the presence of staff trained in
life-saving skills while pediatric patients are present in the facility.
Reporting Period:None
Years Available:6
Data Sets:—
Facility and Surgeon Volume for Bariatric Surgery for Weight Loss, Total Hip Replacement, Total Knee Replacement
Measures the annual volume of procedures and whether surgeons are required to
perform a minimum number of procedures to maintain their privileges, both of
which are associated with better patient outcomes.
Reporting Period:CY2024
Years Available:8
Data Sets:
Gastroenterology Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
General Surgery Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
Ophthalmology Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
Orthopedic Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:5
Data Sets:
Otolaryngology Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:5
Data Sets:
Urology Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
Neurological Surgery Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
Obstetrics and Gynecology Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
Plastic and Reconstructive Surgery Adult Procedure Volume
Total volume of procedures.
Reporting Period:CY2024
Years Available:6
Data Sets:
General Surgery Pediatric Procedure Volume
Total volume of procedures
Reporting Period:CY2024
Years Available:6
Data Sets:
Ophthalmology Pediatric Procedure Volume
Total volume of procedures
Reporting Period:CY2024
Years Available:6
Data Sets:
Orthopedic Pediatric Procedure Volume
Total volume of procedures
Reporting Period:CY2024
Years Available:5
Data Sets:
Otolaryngology Pediatric Procedure Volume
Total volume of procedures
Reporting Period:CY2024
Years Available:5
Data Sets:
Patient Burns (CMS ASC-1)
Patient Burns measures the percentage of patients who experience a burn prior to
discharge from a surgery center.
Reporting Period:01/01/2023 – 12/31/2023
Years Available:1
Data Sets:
Patient Falls (CMS ASC-2)
Patient Falls measures the percentage of patients who experience a fall in a
surgery center.
Reporting Period:01/01/2023 – 12/31/2023
Years Available:1
Data Sets:
Wrong Site, Side, Patient, Procedure, or Implant (CMS ASC-3)
Wrong Site, Side, Patient, Procedure, or Implant measures the percentage of
patients who experience a wrong site, side, patient, procedure, or implant.
Reporting Period:01/01/2023 – 12/31/2023
Years Available:1
Data Sets:
Patient Transfers or Admissions to a Hospital (CMS ASC-4)
Patient Transfers or Admissions to a Hospital measures the percentage of
patients who are transferred or admitted to a hospital upon discharge from a
surgery center.
Reporting Period:01/01/2023 – 12/31/2023
Years Available:1
Data Sets:
Unplanned Hospital Visit after Outpatient Colonoscopy (CMS ASC-12; CMS OP-32)
Unplanned Hospital Visit after Outpatient Colonoscopy measures the rate of
unplanned hospital visits after outpatient colonoscopy that is lower than most
facilities.
Reporting Period:01/01/2021 – 12/31/2023
Years Available:4
Data Sets:
Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures (CMS ASC-17)
Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures measures
the rate of unplanned hospital visits following an orthopedic surgery.
Reporting Period:01/01/2022 – 12/31/2023
Years Available:3
Data Sets:
Hospital Visits After Urology Ambulatory Surgical Center Procedures (CMS ASC-18)
Hospital Visits After Urology Ambulatory Surgical Center Procedures measures the
rate of unplanned hospital visits after urology surgery.
Reporting Period:01/01/2022 – 12/31/2023
Years Available:3
Data Sets:
Implementation of a Safe Surgery Checklist – Outpatient Surgery
Safe Surgery Checklist for Complex Surgery measures the implementation of a safe
surgical checklist for every inpatient procedure to reduce errors via an annual
audit.
Reporting Period:2025
Years Available:6
Data Sets: