01/01/2016 - 12/31/2016 12-month reporting time period used: 07/01/2016 - 06/30/2017 Total number of vaginal deliveries, with Excluded Populations removed. ______ Total number of mothers indicated in question #2 that had an episiotomy procedure performed. ______ 4E: Process Measures of Quality Specifications: See in the Maternity Care Reference Information on pages 83-84. Sufficient Sample: See for instructions for identifying a sufficient sample to answer questions #3-4 and #8-9. Newborn Bilirubin Screening Prior to Discharge 01/01/2016 - 12/31/2016 12-month reporting time period used: 07/01/2016 - 06/30/2017 Yes Did your hospital perform a medical record audit on all cases (or a sufficient sample of them) and measure adherence to the newborn No bilirubin screening prior to discharge clinical guideline? Yes, but fewer than 10 cases If but than 10 cases met the inclusion criteria for the “yes,” met the inclusion criteria for denominator, skip questions #3-5. the denominator Number of cases measured against the guideline, either all cases or a sufficient sample of them (denominator). ______ Number of cases in question #3 that adhere to the clinical process guideline (numerator). ______ Do the responses in questions #3 and #4 represent a sample of Yes No Appropriate DVT Prophylaxis in Women Undergoing Cesarean Section 01/01/2016 - 12/31/2016 reporting time period used: 07/01/2016 - 06/30/2017 Did your hospital perform a medical record audit on all cases (or a Yes sufficient sample of them) and measure adherence to the appropriate DVT prophylaxis in women undergoing cesarean No section clinical guideline? Yes, but fewer than 10 cases If but fewer than 10 cases met the inclusion criteria for the met the inclusion criteria for “yes,” denominator, skip questions #8-10. the denominator
12-month reporting time period used: 01/01/2016 - 12/31/2016 07/01/2016 - 06/30/2017 Total number of vaginal deliveries, with Excluded Populations removed. ______ Total number of mothers indicated in question #2 that had an episiotomy procedure performed. ______ 4E: Process Measures of Quality Specifications: See in the Maternity Care Reference Information on pages 83-84. Sufficient Sample: See for instructions for identifying a sufficient sample to answer questions #3-4 and #8-9. Newborn Bilirubin Screening Prior to Discharge 12-month reporting time period used: 01/01/2016 - 12/31/2016 07/01/2016 - 06/30/2017 Did your hospital perform a medical record audit on all cases (or a sufficient sample of them) and measure adherence to the newborn bilirubin screening prior to discharge clinical guideline? If “yes,” but than 10 cases met the inclusion criteria for the denominator, skip questions #3-5. Yes No Yes, but fewer than 10 cases met the inclusion criteria for the denominator Number of cases measured against the guideline, either all cases or a sufficient sample of them (denominator). ______ Number of cases in question #3 that adhere to the clinical process guideline (numerator). ______ Do the responses in questions #3 and #4 represent a sample of Yes No Appropriate DVT Prophylaxis in Women Undergoing Cesarean Section reporting time period used: 01/01/2016 - 12/31/2016 07/01/2016 - 06/30/2017 Did your hospital perform a medical record audit on all cases (or a sufficient sample of them) and measure adherence to the appropriate DVT prophylaxis in women undergoing cesarean section clinical guideline? If “yes,” but fewer than 10 cases met the inclusion criteria for the denominator, skip questions #8-10. Yes No Yes, but fewer than 10 cases met the inclusion criteria for the denominator
2017Survey_04052017_v3.3.docx