Einstein/Montefiore Department of Medicine

CMS Hospital Performance Measures


Rohit Bhalla, MD
Chief Quality Officer
Assistant Professor (Medicine)

Hospital care measures are a set of criteria defined by the Centers for Medicare & Medicaid Services (CMS) to evaluate how well hospitals care for patients with certain medical conditions or surgical procedures, as well as results from patient surveys about the quality of care they received.

Current Care Measures 

Heart Attack (Acute Myocardial Infarction/AMI)

  1. Aspirin at Arrival
  2. Aspirin at Discharge
  3. Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) for Left Ventricular Systolic Dysfunction
  4. Beta Blocker at Discharge
  5. Fibrinolytic Medication Within 30 Minutes Of Arrival
  6. Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival
  7. Smoking Cessation Advice/Counseling 

Heart Failure 

  1. Evaluation of Left Ventricular Systolic (LVS) Function
  2. Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) for Left Ventricular Systolic Dysfunction
  3. Discharge Instructions
  4. Smoking Cessation Advice/Counseling 


  1. Oxygenation Assessment
  2. Initial Antibiotic Timing
  3. Pneumococcal Vaccination
  4. Influenza Vaccination
  5. Blood Culture Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
  6. Appropriate Initial Antibiotic Selection
  7. Smoking Cessation Advice/Counseling 

Surgical Care Improvement Project 

  1. Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
  2. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
  3. Prophylactic Antibiotic Selection
  4. Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
  5. Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
  6. Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
  7. Surgery Patients with Appropriate Hair Removal

Children's Asthma Care (not applicable to Department of Medicine)

More Information 





Contact Us

Department of Medicine
Albert Einstein College of Medicine
Jack and Pearl Resnick Campus
Belfer Building - Room 1008
1300 Morris Park Avenue
Bronx, NY 10461 (directions)

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Administrative Questions:
Fax: 718-430-8659

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