Physician-specific PPE Reporting measures

This is a list of physician-specific measures available in Clinical Analytics. Because these measures are physician-level, they designed for your Physician Practice Evaluation (PPE) reports and are not available in Scorecards (where measures are encounter-level). Keep in mind that encounter-level measures available in Scorecards are also available in PPE Reporting; the list here is limited to physician-level measures.

NOTE: These measures are based on data we receive from your facility and we do not perform additional calculations in reporting, which is why you do not see measure definitions in the following table and why benchmarks are not available for these measures.

Click here to download this measure list as a PDF: Clinical Analytics Physician measures.

Contact Support for more information about incorporating these measures in your PPE Reporting.

Measure name	Benchmarks available
% Appropriate Transfers	No
% Site Marking Completed	No
% Time Out Completed	No
360 Degree Reviews	No
Anesthesia Delay - Count	No
Anesthesia Delay - Rate	No
Appropriate Follow-up interval for Normal Colonoscopy in Average Risk Patients	No
Avoidable Days	No
Board Certified	No
CABG Prolonged Intubation Odds Ratio	No
Case Presentation	No
Case review with care rated less than acceptable - Major	No
Case Review with care rated less than acceptable - Minor	No
CME Requirements Met	No
CMS non-compliance - Count	No
CMS Non-compliance - Rate	No
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use	No
Combined Query Response Rate	No
Committee Attendance	No
Committee Participation	No
Complaints related to professionalism from Staff	No
Completion of medication reconciliation process on admission with MD signature indicating that process was completed per policy - Rate	No
Completion of Medication Reconciliation Process on Admission with MD signature indicting that process was completed per policy - Count	No
Consultation Performed More Than 1 day After Order Placed	No
Continuing Education	No
CPOE Utilization	No
Dating, Timing and Signing of Orders Rate	No
Delinquent Discharge Summaries - Count	No
Delinquent Discharge Summaries - Rate	No
Delinquent H&Ps	No
Delinquent Operating Room Reports	No
Denials	No
Department Meeting Attendance	No
Department Meeting Participation	No
Dialysis Catheter CLABSI	No
Dialysis Treatments Same Day of Discharge	No
Discrepancy rate frozen section to final	No
Discrepancy Rated 2b RadPeer System	No
Discrepancy Rated 3 RadPeer System	No
Discrepancy Rated 4 RadPeer System	No
Down-coded Charts - Count	No
Down-Coded Charts - Rate	No
Epilepsy Monitoring Unit Average LOS (Group)	No
ER Referrals	No
External Beam Radiotherapy for bone metastases	No
False Negatives	No
Frozen section turnaround time for diagnostic reports within 20 minutes	No
Grievances	No
Illegible Orders sent for Review - Count	No
Illegible Orders Sent for Review - Rate	No
Inappropriate Behavior	No
Inappropriate Blood Utilization - Count	No
Inappropriate Blood Utilization - Rate	No
Inappropriate use of Abbreviations - Count	No
Inappropriate Use of Abbreviations - Rate	No
Incomplete Charts Over 30 days	No
Inpatient Report	No
Medical Record Delinquency - Count	No
Medical Record Delinquency - Rate	No
Medical Record Suspensions	No
Medical Staff Committee Attendance	No
Medication Errors - Count	No
Medication Errors - Rate	No
Meeting Attendance	No
Newborn Readmission Within 14 Days of Discharge	No
Number of Intraoperative neurophysiological monitoring reports received after 2 business days	No
Overall CABG Composite Quality Rating	No
Patient Complaints	No
Patient Compliments	No
Peer Case Reviews	No
Peer Professional Analysis	No
Peer Review - 1	No
Peer Review - 2	No
Peer Review - 3	No
Peer Review - 4	No
Percent Of Surgical Site Infections Within PeriOP Period (rate)	No
Pharmacy Interventions	No
Physician - % Of RBC Transfusions Ordered For A Pre-Transfusion HGB Value < 7.0 g/dL	No
Physician - % Of RBC Transfusions Ordered For A Pre-Transfusion HGB Value >= 8.0 g/dL	No
Physician - % Single Unit RBC Transfusion Orders	No
Physician - Physician - Accession Volume Inpatient	No
Physician - Physician - Accession Volume Outpatient	No
Physician - Accidental Puncture or Laceration - Count	No
Physician - Accidental Puncture or Laceration - Rate	No
Physician - Administrative Suspensions - $300 Fine	No
Physician - Administrative Suspensions - 14 Days Delinquent	No
Physician - Administrative Suspensions - 35 Days	No
Physician - Average Geometric LOS Opportunity	No
Physician - Average Onset Days	No
Physician - Average Time to Newborn Evaluation - Hours	No
Physician - Average Turnaround Time (Excluding STAT) - Count	No
Physician - Average Turnaround Time (Including STAT) - Count	No
Physician - Behavioral Medical Unit Readmission Within 30 Days - Rate	No
Physician - BH Polypharmacy Days	No
Physician - Catheter-Associated Urinary Tract Infection (CAUTI) - Count	No
Physician - Central Line-Associated Bloodstream Infection (CLABSI) - Count	No
Physician - Colorectal Cancer Screening	No
Physician - Combined Query Response - Rate	No
Physician - Community Discharges	No
Physician - Consultation Performed More Than 24 Hours After Order Placed - Count	No
Physician - Decubitus Ulcer - Count	No
Physician - Delinquent ED Notes - Count	No
Physician - Delinquent Office Notes - Count	No
Physician - Delinquent Post Anesthesia Notes - Count	No
Physician - Dialysis Catheter CLABSI - Rate	No
Physician - Discrepancy Rated Clinically Significant in RadPeer System - Count	No
Physician - DVT Occurrence - Rate	No
Physician - Early Elective Deliveries	No
Physician - Early Elective Deliveries - Count	No
Physician - ePrescribing Compliance	No
Physician - Evaluation Completed 24 Hours or More After Discharge - Count	No
Physician - Eye, Mouth, and Dental Injuries - Count	No
Physician - FIM Change Admission to Discharge	No
Physician - FIM Efficiency	No
Physician - Flu Vaccine Compliance - Flag	No
Physician - Global Minor_Major Discrepancy Based on vRad Review - %	No
Physician - H&P's Completed 24 Hours or More After Discharge - Count	No
Physician - HIM delinquency resulting in No Bed List or Penalty List	No
Physician - Hospital Acquired Conditions - Count	No
Physician - Hyperbilirubinemia Readmissions Within 48 Hours - Count	No
Physician - Iatrogenic Pneumothorax - Count	No
Physician - Iatrogenic Pneumothorax - Rate	No
Physician - Imaging Productivity: Read Turnaround Time >6 Hours - Count	No
Physician - Imaging Productivity: Read Turnaround Time >6 Hours - Rate	No
Physician - Mammography/Breast Cancer Screening	No
Physician - Multiple Anti-Psychotic Medication Justification - Count	No
Physician - Newborn Evaluations not Completed Within 24 Hours - Count	No
Physician - Number of No Bed List Occurrences - Count	No
Physician - Number of Peer Review Cases With Score of 4 - Count	No
Physician - Operative Report Not Completed Within 24 Hours - Count	No
Physician - Outpatient Door to Doc	No
Physician - Outpatient ED Throughput	No
Physician - Patient Contacts - Count	No
Physician - Pediatrics (excluding Newborns) Readmission Rate Within 7 Days of Discharge	No
Physician - Peer Review: Appropriate Care	No
Physician - Peer Review: Exceptional Care	No
Physician - Peer Review: Opportunities - Improvement	No
Physician - Peer Review: Opportunities - Major Improvement	No
Physician - Pharmacy Interventions - Count	No
Physician - Pneumococcal Vaccine > 64 years old	No
Physician - Polypharmacy Days - Count	No
Physician - Polypharmacy Days - Rate	No
Physician - Postoperative Wound Dehiscence - Rate	No
Physician - Press Ganey ED Report Patient Satisfaction	No
Physician - PSI-4 - Death Among Surgical Inpatients Count	No
Physician - PSI-6 - Iatrogenic Pneumothorax Count	No
Physician - PSI-9 - Postoperative Hemorrhage or Hematoma Count	No
Physician - PSI-12 - Perioperative PE/DVT Count	No
Physician - PSI-13 - Post-Op Sepsis Count	No
Physician - PSI-14 - Post-Op Wound Dehiscence Count	No
Physician - PSI-15 - Accidental Puncture/Laceration Count	No
Physician - Radiology Cancer Detection Percentage	No
Physician - Radiology Positive - Rate	No
Physician - Radiology Recall Rate	No
Physician - Radiology True Positive - Count	No
Physician - Readmission Rate Within 7 Days	No
Physician - Rehab - ALOS	No
Physician - Rehab - Avg Patient Age	No
Physician - Rehab - Brain Injury - Count	No
Physician - Rehab - Brain Injury - Percentage	No
Physician - Rehab CMI	No
Physician - Rehab - Discharged to Acute Care - Count	No
Physician - Rehab - Discharged to Acute Care - Percentage	No
Physician - Rehab - Discharged to Community - Count	No
Physician - Rehab - Discharged to Community - Percentage	No
Physician - Rehab - Discharged to SNF - Count	No
Physician - Rehab - Discharged to SNF - Percentage	No
Physician - Rehab - General Rehab Medical - Percentage	No
Physician - Rehab - Neurological - Count	No
Physician - Rehab - Neurological - Percentage	No
Physician - Rehab - Orthopedic - Count	No
Physician - Rehab - Orthopedic - Percentage	No
Physician - Rehab - Patient Volume - Count	No
Physician - Rehab - Spinal Cord Injury - Count	No
Physician - Rehab - Spinal Cord Injury - Percentage	No
Physician - Rehab - Stroke - Count	No
Physician - Rehab - Stroke - Count	No
Physician - Rehab - Stroke - Percentage	No
Physician - Rehab - Walk Change Average	No
Physician - Rehab - Walk Change Per Day	No
Physician - Rehab - Wheel Change Average	No
Physician - Rehab - Wheel Change Per Day	No
Physician - Rehab Length Of Stay	No
Physician - Report Completion within 72 Hours - %	No
Physician - Screen Mammography - Count	No
Physician - Serious Safety Events	No
Physician - Statins Prescribed at Discharge - Rate	No
Physician - Stress Test Turnaround Time Goal Not Met - Count	No
Physician - Stress Test Turnaround Time Goal Not Met - Rate	No
Physician - STK-6 - Discharged on Statin Medication	No
Physician - Surgical Pathology Agreement with Unsolicited Extra-Department Review	No
Physician - Surgical Pathology Diagnoses Error - %	No
Physician - Surgical Site Infections - Count	No
Physician - Surgical Site Infections Class 1 - Count	No
Physician - TAT Time Average Inpatient	No
Physician - TAT Time Average Outpatient	No
Physician - Tobacco Use Treatment Provided or Offered - Rate	No
Physician - Total Inpatient Contacts - Count	No
Physician - Total Inpatient Admissions - Count	No
Physician - Unplanned Returns to Surgery - Count	No
Physician - Unplanned Returns to Surgery - Rate	No
Physician - VTE Prophylaxis (VTE-1 & VTE-2) - Count	No
Physician No Bed List for HIM Delinquency	No
Positive Feedback Letters from Patient, Family and Staff	No
Post-Op Bleeding Tonsillectomy	No
Post-procedure Assessment Completed - Count	No
Post-Procedure Assessment Completed - Rate	No
Pre-procedure Anesthesia Assessment Completed Prior to Incision - Count	No
Pre-procedure Anesthesia Assessment Completed Prior to Incision - Rate	No
Progress Notes Dated and Signed	No
Proportion of PCI procedures with Creatinine Assessed pre and post PCI (rate)	No
Radiology Over-reads - Count	No
Radiology Over-reads - Rate	No
Readmission within 7 days of discharge for PN (count)	No
Readmission within 7 days of discharge for PN (rate)	No
Re-admissions within 7 days of discharge for COPD (count)	No
Re-admissions within 7 days of discharge for COPD (rate)	No
Reappointment Peer Evaluation	No
Reintubation Prior to PACU Discharge	No
Re-operation for Cataract surgery related to lens issues	No
Report Turn Around Time	No
Response time to OB for epidural	No
Response to Consult Request	No
Risk Management Concerns	No
Sentinel Events	No
Staff Complaints	No
Suspension	No
Turnaround Time (Excluding STAT) > 6 Hours	No
Turnaround Time (Excluding STAT) >12 hrs - Count	No
Turnaround Time Complete to Final (Inpatient)	No
Turnaround Time Complete to Final (Outpatient)	No
Unexcused Anesthesia Late Start First Case of the Day (count)	No
Unexcused Late Start First Case Of Day - Count	No
Use Of SCD For DVT Prophylaxis	No
Use of SCD for DVT Prophylaxis (rate)	No
Ventilator Associated Events Related To Ventilator Changes	No
Verbal Order Compliance	No