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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.

Leapfrog Hospital Survey

An annual survey providing in-depth insights into quality and safety standards for hospitals.

Leapfrog ASC Public Reporting Program

A program evaluating safety and quality for ambulatory surgery centers using CMS data, national accreditation standards, and Leapfrog ASC Survey 2.0 results.

Hospital Safety Grade

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.

Search for Measures

Leapfrog Hospital Survey

Leapfrog ASC Public Reporting Program

Leapfrog Hospital Safety Grade

Patient Rights and Ethics

Measure	Measure Description	Reporting Period	Years Data Available
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.	2026	5
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.	2026	3
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.	2026	4
Taking Responsibility for Never Events	Taking Responsibility for 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.	2026	20

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:2026

Years Available:5

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:2026

Years Available:3

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:2026

Years Available:4

Data Sets:

Taking Responsibility for Never Events

Taking Responsibility for 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:2026

Years Available:20

Data Sets:

Patient Safety Practices

Measure	Measure Description	Reporting Period	Years Data Available
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	15
Effective Leadership to Prevent Errors	Effective Leadership to Prevent Errors 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.	2026	22
Culture of Safety	Culture of Safety measures the implementation of evidence-based practices for Culture Measurement, Feedback, and Intervention endorsed by the National Quality Forum, which reduce adverse events.	2026	22
Identification and Mitigation of Risks and Hazards	Identification and Mitigation of Risks and Hazards 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.	2026	22
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.	CY2025	4
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.	CY2025	4
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.	2026	4
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.	2026	7

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:15

Data Sets:

Effective Leadership to Prevent Errors

Effective Leadership to Prevent Errors 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:2026

Years Available:22

Data Sets:

Culture of Safety

Culture of Safety 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:2026

Years Available:22

Data Sets:

Identification and Mitigation of Risks and Hazards

Identification and Mitigation of Risks and Hazards 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:2026

Years Available:22

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:CY2025

Years Available:4

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:CY2025

Years Available:4

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:2026

Years Available:4

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:2026

Years Available:7

Data Sets:

Medication Safety

Measure	Measure Description	Reporting Period	Years Data Available
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.	2026	17
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.	2026	11
Medication Reconciliation	Medication Reconciliation measures the rate of unintentional medication discrepancies resulting from the medication reconciliation process.	2026	9
Medication and Allergy Documentation During Outpatient Surgery	Medication and Allergy 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.	CY2025	7

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:2026

Years Available:17

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:2026

Years Available:11

Data Sets:

Medication Reconciliation

Medication Reconciliation measures the rate of unintentional medication discrepancies resulting from the medication reconciliation process.

Reporting Period:2026

Years Available:9

Data Sets:

Medication and Allergy Documentation During Outpatient Surgery

Medication and Allergy 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:CY2025

Years Available:7

Data Sets:

Patient Experience

Measure	Measure Description	Reporting Period	Years Data Available
Communication with Nurses (CMS H-COMP 1)	Communication with Nurses measures patient experience with nurse communication during a hospitalization.	01/01/2024-12/31/2024	15
Communication with Doctors (CMS H-COMP 2)	Communication with Doctors measures patient experience with doctor communication during a hospitalization.	01/01/2024-12/31/2024	15
Staff Responsiveness (CMS H-COMP 3)	Staff Responsiveness measures patient experience with staff responsiveness during a hospitalization.	01/01/2024-12/31/2024	15
Communication about Medicines (CMS H-COMP 5)	Communication about Medicines measures patient experience with receiving clear communication about their medicines during a hospitalization.	01/01/2024-12/31/2024	15
Discharge Information (CMS H-COMP 6)	Discharge information measures patient experience with receiving clear discharge information during a hospitalization.	01/01/2024-12/31/2024	15
Outpatient and Ambulatory Surgery Patient Experience (OAS CAHPS)	OAS CAHPS measures patient experience during a same-day surgery.	2025	7
Pediatric Patient Experience (CAHPS Child Hospital Survey)	Pediatric Patient Experience measures patient and family experience during a hospitalization.	2026	9

Communication with Nurses (CMS H-COMP 1)

Communication with Nurses measures patient experience with nurse communication during a hospitalization.

Reporting Period:01/01/2024-12/31/2024

Years Available:15

Data Sets:

Communication with Doctors (CMS H-COMP 2)

Communication with Doctors measures patient experience with doctor communication during a hospitalization.

Reporting Period:01/01/2024-12/31/2024

Years Available:15

Data Sets:

Staff Responsiveness (CMS H-COMP 3)

Staff Responsiveness measures patient experience with staff responsiveness during a hospitalization.

Reporting Period:01/01/2024-12/31/2024

Years Available:15

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:01/01/2024-12/31/2024

Years Available:15

Data Sets:

Discharge Information (CMS H-COMP 6)

Discharge information measures patient experience with receiving clear discharge information during a hospitalization.

Reporting Period:01/01/2024-12/31/2024

Years Available:15

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:7

Data Sets:

Pediatric Patient Experience (CAHPS Child Hospital Survey)

Pediatric Patient Experience measures patient and family experience during a hospitalization.

Reporting Period:2026

Years Available:9

Data Sets:

Healthcare Associated Infections

Measure	Measure Description	Reporting Period	Years Data Available
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).	CY2025	10
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).	CY2025	10
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).	CY2025	10
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).	CY2025	10
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).	CY2025	10
Infection Surveillance for ASCs Performing Breast Surgeries, Laminectomies, Herniorrhaphies, or Knee Prosthesis Procedures: NHSN OPC SSI Reporting Plans	Infection Surveillance for ASCs Performing Breast Surgeries, Laminectomies, Herniorrhaphies, or Knee Prosthesis Procedures: NHSN OPC SSI Reporting Plans measures CDC guidance regarding surgical site infection surveillance following breast surgery, laminectomy, herniorrhaphy, and knee prosthesis.	CY2025	7

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:CY2025

Years Available:10

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:CY2025

Years Available:10

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:CY2025

Years Available:10

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:CY2025

Years Available:10

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:CY2025

Years Available:10

Data Sets:

Infection Surveillance for ASCs Performing Breast Surgeries, Laminectomies, Herniorrhaphies, or Knee Prosthesis Procedures: NHSN OPC SSI Reporting Plans

Infection Surveillance for ASCs Performing Breast Surgeries, Laminectomies, Herniorrhaphies, or Knee Prosthesis Procedures: NHSN OPC SSI Reporting Plans measures CDC guidance regarding surgical site infection surveillance following breast surgery, laminectomy, herniorrhaphy, and knee prosthesis.

Reporting Period:CY2025

Years Available:7

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.	2026	25
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.	2026	2

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:2026

Years Available:25

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:2026

Years Available:2

Data Sets:

Maternity Care

Measure	Measure Description	Reporting Period	Years Data Available
Volume of Deliveries	Total number of newborn deliveries.	CY2025	9
Midwives	Patients have access to certified midwives for labor and delivery.	2026	4
Doulas	Patients can bring their own doula for support during labor and delivery, and/or the hospital employs or has contracts with doulas.	2026	4
Breastfeeding/lactation support	Patients have access to linical lactation care, education, and support provided by an International Board Certified Lactation Consultant® (IBCLC®) and/or education and counseling provided by other lactation consultants, counselors, educators, and/or specialists.	2026	4
Vaginal Deliveries after Cesarean Section	Patients have access to a vaginal delivery after a previous cesarean section.	2026	4
Contraception services offered in the immediate postpartum period before delivery discharge	Patients have access to tubal ligation, Bilateral salpingectomy, or long-acting reversible contraception in combination with cesarean section or shortly after vaginal birth.	2026	4
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.	2026	18
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.	CY2025	12
Episiotomy	Episiotomy measures the episiotomy rate during vaginal deliveries, which can cause long-term complications among mothers.	CY2025	15
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.	CY2025	18
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.	CY2025	18
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.	CY2025	19

Volume of Deliveries

Total number of newborn deliveries.

Reporting Period:CY2025

Years Available:9

Data Sets:

Midwives

Patients have access to certified midwives for labor and delivery.

Reporting Period:2026

Years Available:4

Data Sets:

Doulas

Patients can bring their own doula for support during labor and delivery, and/or the hospital employs or has contracts with doulas.

Reporting Period:2026

Years Available:4

Data Sets:

Breastfeeding/lactation support

Patients have access to linical lactation care, education, and support provided by an International Board Certified Lactation Consultant® (IBCLC®) and/or education and counseling provided by other lactation consultants, counselors, educators, and/or specialists.

Reporting Period:2026

Years Available:4

Data Sets:

Vaginal Deliveries after Cesarean Section

Patients have access to a vaginal delivery after a previous cesarean section.

Reporting Period:2026

Years Available:4

Data Sets:

Contraception services offered in the immediate postpartum period before delivery discharge

Patients have access to tubal ligation, Bilateral salpingectomy, or long-acting reversible contraception in combination with cesarean section or shortly after vaginal birth.

Reporting Period:2026

Years Available:4

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:2026

Years Available:18

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:CY2025

Years Available:12

Data Sets:

Episiotomy

Episiotomy measures the episiotomy rate during vaginal deliveries, which can cause long-term complications among mothers.

Reporting Period:CY2025

Years Available:15

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:CY2025

Years Available:18

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:CY2025

Years Available:18

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:CY2025

Years Available:19

Data Sets:

Pediatric Care

Measure	Measure Description	Reporting Period	Years Data Available
Pediatric Patient Experience (CAHPS Child Hospital Survey)	Pediatric Patient Experience measures patient and family experience during a hospitalization.	2026	9
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.	CY2025	9
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.	CY2025	9
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.	2026	2
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.	CY2025	6

Pediatric Patient Experience (CAHPS Child Hospital Survey)

Pediatric Patient Experience measures patient and family experience during a hospitalization.

Reporting Period:2026

Years Available:9

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:CY2025

Years Available:9

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:CY2025

Years Available:9

Data Sets:

Pediatric ICU Physician Staffing (IPS)

Reporting Period:2026

Years Available:2

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:CY2025

Years Available:6

Data Sets:

Inpatient Surgery

Measure	Measure Description	Reporting Period	Years Data Available
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	9
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.	CY2025	6
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.	CY2025	6
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.	CY2025	6
Use of a Safe Surgery Checklist - Inpatient Surgery	Use of a Safe Surgery Checklist - Inpatient Surgery measures the implementation of a safe surgical checklist for every inpatient procedure to reduce errors via an annual audit.	2026	5

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:CY2025

Years Available:9

Data Sets:

Mitral Valve Repair and Replacement Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Open Aortic Procedures Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Bariatric Surgery for Weight Loss Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Lung Resection for Cancer Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Esophageal Resection for Cancer Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Pancreatic Resection for Cancer Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Rectal Cancer Surgery Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:9

Data Sets:

Norwood Procedure (Congenital Heart Surgery)

Reporting Period:CY2025

Years Available:6

Data Sets:

Total Hip Replacement Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:6

Data Sets:

Total Knee Replacement Hospital and Surgeon Volume

Reporting Period:CY2025

Years Available:6

Data Sets:

Use of a Safe Surgery Checklist - Inpatient Surgery

Use of a Safe Surgery Checklist - Inpatient Surgery measures the implementation of a safe surgical checklist for every inpatient procedure to reduce errors via an annual audit.

Reporting Period:2026

Years Available:5

Data Sets:

Outpatient Surgery

Measure	Measure Description	Reporting Period	Years Data Available
Percentage of Cataract Surgery Patients Who Had a Unplanned Additional Eye Surgery (Anterior Virectomy) (CMS ASC-14)	Measures the percentage of cataract surgery patients who had an additional eye surgery after their initial procedure.	01/01/2024-12/31/2024	1
Rate of Unplanned Hospital Visits Within 7 Days of a General Surgery at an ASC (CMS ASC-19)	Measures the rate of unplanned hospital visits after general surgery.	01/01/2023-12/31/2024	1
Clinicians Certified in Pediatric Advanced Life Support Always Present	Clinicians Certified in Adult Advanced Life Support Always Present measures the presence of staff trained in life-saving skills while adult patients are present in the facility.	2026	7
Clinicians Certified in Adult Advanced Life Support Always Present	Clinicians Certified in Pediatric Advanced Life Support Always Present measures the presence of staff trained in life-saving skills while pediatric patients are present in the facility.	2026	7
National Volume Standards 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.	CY2025	9
Gastroenterology Adult Procedure Volume	Total volume of procedures.	CY2025	7
General Surgery Adult Procedure Volume	Total volume of procedures.	CY2025	7
Ophthalmology Adult Procedure Volume	Total volume of procedures.	CY2025	7
Orthopedic Adult Procedure Volume	Total volume of procedures.	CY2025	6
Otolaryngology Adult Procedure Volume	Total volume of procedures.	CY2025	6
Urology Adult Procedure Volume	Total volume of procedures.	CY2025	7
Neurological Surgery Adult Procedure Volume	Total volume of procedures.	CY2025	7
Obstetrics and Gynecology Adult Procedure Volume	Total volume of procedures.	CY2025	7
Plastic and Reconstructive Surgery Adult Procedure Volume	Total volume of procedures.	CY2025	7
General Surgery Pediatric Procedure Volume	Total volume of procedures	CY2025	7
Ophthalmology Pediatric Procedure Volume	Total volume of procedures	CY2025	7
Orthopedic Pediatric Procedure Volume	Total volume of procedures	CY2025	6
Otolaryngology Pediatric Procedure Volume	Total volume of procedures	CY2025	6
Percentage of Patients Who Experience a Burn Prior to Discharge from the ASC (CMS ASC-1)	Measures the percentage of patients who experience a burn prior to discharge from a surgery center.	01/01/2024-12/31/2024	2
Percentage of Patients Who Experience a Fall Within the ASC (CMS ASC-2)	Measures the percentage of patients who experience a fall in a surgery center.	01/01/2024-12/31/2024	2
Percentage of Patients Who Experience a Wrong Site, Side, Patient, Procedure, or Implant (CMS ASC-3)	Measures the percentage of patients who experience a wrong site, side, patient, procedure, or implant.	01/01/2024-12/31/2024	2
Percentage of Patients Who Are Transferred or Admitted to a Hospital Upon Discharge from the ASC (CMS ASC-4)	Measures the percentage of patients who are transferred or admitted to a hospital upon discharge from a surgery center.	01/01/2024-12/31/2024	2
Rate of Unplanned Hospital Visits within 7 days of an Outpatient Colonoscopy (CMS ASC-12; CMS OP-32)	Measures the rate of unplanned hospital visits after outpatient colonoscopy.	01/01/2024-12/31/2024	4
Rate of Unplanned Hospital Visits within 7 Days of an Orthopedic Surgery at an ASC (CMS ASC-17)	Measures the rate of unplanned hospital visits following an orthopedic surgery.	01/01/2023-12/31/2024	4
Hospital Visits After Urology Ambulatory Surgical Center Procedures (CMS ASC-18)	Measures the rate of unplanned hospital visits after urology surgery.	01/01/2023-12/31/2024	4
Use of a Safe Surgery Checklist – Outpatient Surgery	Use of a Safe Surgery Checklist – Outpatient Surgerymeasures the implementation of a safe surgical checklist for every inpatient procedure to reduce errors via an annual audit.	2026	6

Percentage of Cataract Surgery Patients Who Had a Unplanned Additional Eye Surgery (Anterior Virectomy) (CMS ASC-14)

Measures the percentage of cataract surgery patients who had an additional eye surgery after their initial procedure.

Reporting Period:01/01/2024-12/31/2024

Years Available:1

Data Sets:

Rate of Unplanned Hospital Visits Within 7 Days of a General Surgery at an ASC (CMS ASC-19)

Measures the rate of unplanned hospital visits after general surgery.

Reporting Period:01/01/2023-12/31/2024

Years Available:1

Data Sets:

Clinicians Certified in Pediatric Advanced Life Support Always Present

Clinicians Certified in Adult Advanced Life Support Always Present measures the presence of staff trained in life-saving skills while adult patients are present in the facility.

Reporting Period:2026

Years Available:7

Data Sets:

Clinicians Certified in Adult Advanced Life Support Always Present

Clinicians Certified in Pediatric Advanced Life Support Always Present measures the presence of staff trained in life-saving skills while pediatric patients are present in the facility.

Reporting Period:2026

Years Available:7

Data Sets:

National Volume Standards for Bariatric Surgery for Weight Loss, Total Hip Replacement, Total Knee Replacement

Reporting Period:CY2025

Years Available:9

Data Sets:

Gastroenterology Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

General Surgery Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

Ophthalmology Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

Orthopedic Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:6

Data Sets:

Otolaryngology Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:6

Data Sets:

Urology Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

Neurological Surgery Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

Obstetrics and Gynecology Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

Plastic and Reconstructive Surgery Adult Procedure Volume

Total volume of procedures.

Reporting Period:CY2025

Years Available:7

Data Sets:

General Surgery Pediatric Procedure Volume

Total volume of procedures

Reporting Period:CY2025

Years Available:7

Data Sets:

Ophthalmology Pediatric Procedure Volume

Total volume of procedures

Reporting Period:CY2025

Years Available:7

Data Sets:

Orthopedic Pediatric Procedure Volume

Total volume of procedures

Reporting Period:CY2025

Years Available:6

Data Sets:

Otolaryngology Pediatric Procedure Volume

Total volume of procedures

Reporting Period:CY2025

Years Available:6

Data Sets:

Percentage of Patients Who Experience a Burn Prior to Discharge from the ASC (CMS ASC-1)

Measures the percentage of patients who experience a burn prior to discharge from a surgery center.

Reporting Period:01/01/2024-12/31/2024

Years Available:2

Data Sets:

Percentage of Patients Who Experience a Fall Within the ASC (CMS ASC-2)

Measures the percentage of patients who experience a fall in a surgery center.

Reporting Period:01/01/2024-12/31/2024

Years Available:2

Data Sets:

Percentage of Patients Who Experience a Wrong Site, Side, Patient, Procedure, or Implant (CMS ASC-3)

Measures the percentage of patients who experience a wrong site, side, patient, procedure, or implant.

Reporting Period:01/01/2024-12/31/2024

Years Available:2

Data Sets:

Percentage of Patients Who Are Transferred or Admitted to a Hospital Upon Discharge from the ASC (CMS ASC-4)

Measures the percentage of patients who are transferred or admitted to a hospital upon discharge from a surgery center.

Reporting Period:01/01/2024-12/31/2024

Years Available:2

Data Sets:

Rate of Unplanned Hospital Visits within 7 days of an Outpatient Colonoscopy (CMS ASC-12; CMS OP-32)

Measures the rate of unplanned hospital visits after outpatient colonoscopy.

Reporting Period:01/01/2024-12/31/2024

Years Available:4

Data Sets:

Rate of Unplanned Hospital Visits within 7 Days of an Orthopedic Surgery at an ASC (CMS ASC-17)

Measures the rate of unplanned hospital visits following an orthopedic surgery.

Reporting Period:01/01/2023-12/31/2024

Years Available:4

Data Sets:

Hospital Visits After Urology Ambulatory Surgical Center Procedures (CMS ASC-18)

Measures the rate of unplanned hospital visits after urology surgery.

Reporting Period:01/01/2023-12/31/2024

Years Available:4

Data Sets:

Use of a Safe Surgery Checklist – Outpatient Surgery

Use of a Safe Surgery Checklist – Outpatient Surgerymeasures the implementation of a safe surgical checklist for every inpatient procedure to reduce errors via an annual audit.

Reporting Period:2026

Years Available:6

Data Sets: