01/01/2015 - 09/30/2015 reporting time period used: 10/01/2015 - 06/30/2016 Total number of vaginal deliveries during the reporting period 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 70-71. Sufficient Sample: See for instructions for identifying a sufficient sample to answer questions #3-4 and #8-9. Newborn Bilirubin Screening to Discharge 01/01/2015 - 09/30/2015 9-month reporting time period used: 10/01/2015 - 06/30/2016 Has your hospital performed a medical record audit on all cases (or a sufficient sample of them) for the Reporting Time Period and Yes measured adherence to the newborn bilirubin screening prior to No discharge clinical guideline? Yes, but fewer than 10 cases met the inclusion criteria for the denominator If but fewer than 10 cases met the inclusion criteria for the “yes,” denominator, skip questions #3-5. Number of cases measured against the guideline, either all cases ______ or a sufficient sample of them (denominator) Number of in question #3 that adhere to the clinical process ______ guideline (numerator) Yes Do the responses in questions #3 and #4 represent a sample of No cases? Appropriate DVT Prophylaxis in Undergoing Cesarean Section 01/01/2015 - 09/30/2015 reporting time period used: 10/01/2015 - 06/30/2016 Yes Has your hospital performed a medical record audit on all cases (or No a sufficient sample of them) for the Reporting Time Period and Yes, but fewer than 10 cases measured adherence to the appropriate DVT prophylaxis in women met the inclusion criteria for undergoing cesarean section clinical guideline? the denominator
reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Total number of vaginal deliveries during the reporting period 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 70-71. Sufficient Sample: See for instructions for identifying a sufficient sample to answer questions #3-4 and #8-9. Newborn Bilirubin Screening to Discharge 9-month reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Has your hospital performed a medical record audit on all cases (or a sufficient sample of them) for the Reporting Time Period and measured adherence to the newborn bilirubin screening prior to discharge clinical guideline? If “yes,” but fewer 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 in question #3 that adhere to the clinical process guideline (numerator) ______ Do the responses in questions #3 and #4 represent a sample of cases? Yes No Appropriate DVT Prophylaxis in Undergoing Cesarean Section reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Has your hospital performed a medical record audit on all cases (or a sufficient sample of them) for the Reporting Time Period and measured adherence to the appropriate DVT prophylaxis in women undergoing cesarean section clinical guideline? Yes No Yes, but fewer than 10 cases met the inclusion criteria for the denominator
2016Survey_Final_Updated09302016.docx