• Regulatory & Quality Epic Tools - (Quick Start Guide) Regulatory and Quality reporting tools are an essential part of monitoring performance and improvement for different quality programs.  This handout focuses on standard Epic tools that support Center for Medicare and Medicaid (CMS) and The Joint Commission (TJC) programs including dashboards, scorecards, how to investigate and troubleshoot measure outcomes, tips for submission, and more.  It can be used as a reference or as a training guide for users new to the quality space.
• Eligible Clinician Maintenance Provider Blueprint (Handout) - Provider Blueprints allow users to quickly update provider records in Hyperspace.  The blueprint is limited to items needed for routine quality maintenance such as marking a clinician as eligible for CMS quality programs. 
• Total Hip Arthroplasty and Total Knee Arthroplasty Patient Reported Outcome Performance Measure - (Handout) Total Hip Arthroplasty and Total Knee Arthroplasty Patient Reported Outcome Performance Measure (THA and TKA PRO-PM) is required for Centers for Medicare & Medicaid Services (CMS) Inpatient and Outpatient Quality Reporting programs. It includes perioperative questionnaires that aim to capture the patient’s self-assessment of pain and function before and after THA and/or TKA, and to measure improvement in a risk-standardized way.

• Hospital Harm Pressure Injury (Handout) - Hospital Harm – Pressure Injury (HH-PI or CMS 826) is part of the CMS Inpatient Quality Reporting program and measures the number of hospitalizations where patients develop a new deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury.
• Hospital Harm Falls with Injury -  (Handout) Hospital Harm Falls with Injury (Handout) - Hospital Harm - Falls with Injury (HH-FI or CMS 1017) is part of the CMS Inpatient Quality Reporting program and measures the number of hospitalizations where a fall with a major or moderate injury occurs.
• Malnutrition Care Score - (Handout) Malnutrition Care Score (MCS) or CMS 986 is part of the CMS Inpatient Quality Reporting program. It assesses the percentage of eligible encounters of adults aged 18 years and older, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care based on the patient’s level of malnutrition risk and severity.
• Venous Thromboembolism Prophylaxis - (Handout) Venous Thromboembolism Prophylaxis (VTE) is part of two quality measures in the CMS Inpatient Quality Reporting program (CMS 108 VTE-1 and CMS 190 VTE-2).  It assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given.

Screening for Depression and Follow-Up Plan - (Handout) Screening for Depression and Follow-Up Plan (CMS-2) is a quality measure in the CMS Merit-based Incentive Payment System (MIPS) and the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) program. This measure requires depression assessment and plan documentation annually for all patients aged 12 and older.