2016 Standard Quality Measure Set

About the SQMS

SQMS measures are reliable, useful, and relevant to statewide quality priorities. The set is updated annually to reflect changes in standardized sets and stakeholder needs.

CHIA uses multiple data sources to report on the SQMS and to ensure that performance can be compared to national standards.

Maintaining the SQMS

The Executive Director of CHIA chairs the Statewide Quality Advisory Committee, a stakeholder advisory group of consumer advocates, providers, and insurers that meets six times per year to discuss uses for the SQMS and updates to the measure set.

Using the SQMS

CHIA reported on many of the 2015 SQMS in the 2015 Focus on Provider Quality. In addition to CHIA's reporting, state agencies use measures from the SQMS to evaluate the quality of new care delivery models, and payers can use the set for tiering.

See Also: CHIA's 2016 Quality Measure Catalog (Excel).

2016 Standard Quality Measure Set

Newly added measures for the 2016 SQMS are higlighted. For measures that CHIA has reported, the table below lists the data source.

Physician/Group Measures

Measure/Tool Name	Set	Steward	NQF #	Data Source for CHIA Reporting
Consumer Assessment of Healthcare Providers and Systems (CAHPS) - Clinician & Group Survey	CAHPS	AHRQ	5	MHQP
Adherence to Antipsychotics for Individuals with Schizophrenia	HEDIS	NCQA	1879
Adolescent well-care visits	HEDIS	NCQA
Adult BMI Assessment	HEDIS	NCQA
Adults' access to preventive/ambulatory health services	HEDIS	NCQA
Annual dental visit	HEDIS	NCQA
Antidepressant medication management	HEDIS	NCQA	105	MHQP
Appropriate testing of children with pharyngitis	HEDIS	NCQA	2	MHQP
Appropriate treatment for children with upper respiratory infection	HEDIS	NCQA	69	MHQP
Aspirin Use and Discussion	HEDIS	NCQA
Asthma Medication Ratio	HEDIS	NCQA	1800
Avoidance of antibiotic treatment in adults with acute bronchitis	HEDIS	NCQA	58
Breast cancer screening	HEDIS	NCQA	2372	MHQP
CAHPS Health Plan Survey v 3.0 Children with Chronic Conditions Supplement	HEDIS	NCQA	9
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia	HEDIS	NCQA	1933
Care for older adults - medication review	HEDIS	NCQA	553
Cervical cancer screening	HEDIS	NCQA	32	MHQP
Childhood immunization status	HEDIS	NCQA	38
Children and adolescents' access to primary care practitioners	HEDIS	NCQA
Chlamydia screening in women	HEDIS	NCQA	33	MHQP
Colorectal cancer screening	HEDIS	NCQA	34	MHQP
Comprehensive diabetes care	HEDIS	NCQA		MHQP
Controlling high blood pressure	HEDIS	NCQA	18
Counseling on Physical Activity in Older Adults	HEDIS	NCQA	29
Diabetes Monitoring for People with Diabetes and Schizophrenia	HEDIS	NCQA	1934
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who are Using Antipsychotic Medications	HEDIS	NCQA	1932
Disease modifying anti-rheumatic drug therapy for rheumatoid arthritis	HEDIS	NCQA	54
Fall Risk Management	HEDIS	NCQA	35
Flu shots for adults ages 18-64	HEDIS	NCQA	39
Flu shots for adults ages 65 and older	HEDIS	NCQA	39
Follow-up after hospitalization for mental illness	HEDIS	NCQA	576
Follow-up care for children prescribed ADHD medication	HEDIS	NCQA	108	MHQP
Frequency of ongoing prenatal care	HEDIS	NCQA	1391
Human Papillomavirus Vaccine for Female Adolescents	HEDIS	NCQA	1959
Immunizations for adolescents	HEDIS	NCQA	1407
Initiation and engagement of alcohol and other drug dependence treatment	HEDIS	NCQA	4
Lead screening in children	HEDIS	NCQA
Medical Assistance With Smoking and Tobacco Use Cessation	HEDIS	NCQA	27
Medication management for people with asthma	HEDIS	NCQA	1799
Medication reconciliation post-discharge	HEDIS	NCQA	554
Metabolic Monitoring for Children and Adolescents on Antipsychotics	HEDIS	NCQA
Non-Recommended Cervical Cancer Screening in Adolescent Females	HEDIS	NCQA
Non-Recommended PSA-Based Screening in Older Men	HEDIS	NCQA
Osteoporosis management in women who had a fracture	HEDIS	NCQA	53
Osteoporosis Testing in Older Women	HEDIS	NCQA	37
Persistence of beta-blocker treatment after a heart attack	HEDIS	NCQA	71
Pharmacotherapy of chronic obstructive pulmonary disease (COPD) exacerbation	HEDIS	NCQA
Pneumococcal vaccination status for older adults	HEDIS	NCQA	43
Potentially harmful drug-disease interactions in the elderly	HEDIS	NCQA
Prenatal and postpartum care	HEDIS	NCQA	1517
Therapeutic monitoring: Annual monitoring for patients on persistent medications	HEDIS	NCQA	2371	MHQP
Urinary Incontinence Management in Older Adults	HEDIS	NCQA	30
Use of appropriate medications for people with asthma	HEDIS	NCQA	36	MHQP
Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics	HEDIS	NCQA
Use of high-risk medications in the elderly	HEDIS	NCQA	22
Use of imaging studies for low back pain	HEDIS	NCQA	52	MHQP
Use of Multiple Concurrent Antipsychotics in Children and Adolescents	HEDIS	NCQA
Use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD)	HEDIS	NCQA	577
Weight assessment and counseling for nutrition and physical activity for children/adolescents	HEDIS	NCQA	24
Well-child visits in the first 15 months of life	HEDIS	NCQA	1392	MHQP
Well-child visits in the third, fourth, fifth and sixth years of life	HEDIS	NCQA	1516	MHQP
Asthma in younger adults admission rate (PQI 15)	PQI	AHRQ	283	HDD
Chronic obstructive pulmonary disease (COPD) or Asthma in Older Adults Admission Rate (PQI 5)	PQI	AHRQ	275	HDD
Diabetes Short-Term Complications Admission Rate (PQI 1)	PQI	AHRQ	272	HDD
Heart Failure Admission Rate (PQI 8)	PQI	AHRQ	277	HDD
Low Birth Weight Rate (PQI 9)	PQI	AHRQ	278	HDD
Asthma Emergency Department Visits		Alabama Medicaid Agency
Depression screening by 18 years of age		NCQA	1515
Depression Utilization of the PHQ-9 Tool		MN Community Measurement	712
Maternal Depression Screening		NCQA	1401
Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention		AMA-PCPI	28
Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling		AMA-PCPI	2152
Screening for Clinical Depression and Follow-up Plan		CMS	418

Hospital Measures

Measure/Tool Name	Set	Steward	NQF #	Data Source for CHIA Reporting
Fibrinolytic therapy received within 30 minutes of hospital arrival (AMI 7a)	AMI	CMS	164	CMS Hospital Compare
Home Management Plan of Care Document Given to Patient/Caregiver (CAC 3)	CAC	The Joint Commission		CMS Hospital Compare
Relievers for inpatient asthma (CAC 1)	CAC	The Joint Commission		CMS Hospital Compare
Systemic corticosteroids for inpatient asthma (CAC 2)	CAC	The Joint Commission	144	CMS Hospital Compare
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Includes 14 measures: 11 HCAHPS and CTM-3)	CAHPS	AHRQ	166/228	CMS Hospital Compare
Patients discharged on multiple antipsychotic medications (HBIPS 4)	HBIPS	The Joint Commission
Post discharge continuing care plan created (HBIPS 6)	HBIPS	The Joint Commission	557
Post-discharge continuing care plan transmitted to next level of care provider upon discharge (HBIPS 7)	HBIPS	The Joint Commission	558
Detailed Discharge Instructions (HF 1)	HF	CMS		CMS Hospital Compare
Evaluation of Left Ventricular Systolic (LVS) Function (HF 2)	HF	CMS		CMS Hospital Compare
Influenza Immunization (IMM 2)	IMM	CMS	1659	CMS Hospital Compare
Antenatal Steroids (for high risk newborn deliveries) (PC-03)	PC	The Joint Commission	476	Leapfrog
Cesarean Section (PC-02)	PC	The Joint Commission	471	Leapfrog
Elective Deliveries (PC-01)	PC	The Joint Commission	469	Leapfrog
Exclusive Breast Milk Feeding (PC-05)	PC	The Joint Commission	480
Health Care-Associated Bloodstream Infections in Newborns (PC-04)	PC	The Joint Commission	1731
Birth Trauma Rate: Injury to Neonates (PSI 17)	PSI	AHRQ		HDD
Central Venous Catheter-related Blood Stream Infection Rate (PSI 7)	PSI	AHRQ		HDD
Iatrogenic Pneumothorax Rate (PSI 6)	PSI	AHRQ	346	HDD
Obstetric Trauma: Vaginal Delivery with Instrument (PSI 18)	PSI	AHRQ		HDD
Obstetric Trauma: Vaginal Delivery without Instrument (PSI 19)	PSI	AHRQ		HDD
Patient Safety Composite (PSI 90)	PSI	AHRQ	531	HDD
Perioperative Pulmonary Embolism or Deep Vein Thrombosis (PE/DVT) Rate (PSI 12)	PSI	AHRQ	450	HDD
Post-operative Hip Fracture Rate (PSI 8)	PSI	AHRQ		HDD
Post-operative Respiratory Failure Rate (PSI 11)	PSI	AHRQ	533	HDD
Pressure Ulcer Rate (PSI 3)	PSI	AHRQ		HDD
Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate (PSI 15)	PSI	AHRQ	345	HDD
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who received a Beta-Blocker During the Perioperative Period (SCIP-Card-2)	SCIP-Card	CMS	284	CMS Hospital Compare
Cardiac Surgery Patients With Controlled Postoperative Blood Glucose (SCIP-Inf-4)	SCIP-Inf	CMS	300	CMS Hospital Compare
Prophylactic antibiotics discontinued within 24 hours after surgery end time (SCIP-Inf-3a)	SCIP-Inf	CMS	529	CMS Hospital Compare
Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery (SCIP-VTE-2)	SCIP-VTE	CMS	218	CMS Hospital Compare
Severe Sepsis & Septic Shock: Management Bundle (SEP-1)	SEP	Henry Ford Hospital	500	CMS Hospital Compare
Discharged on Statin (STK-6)	STK	The Joint Commission	439	CMS Hospital Compare
Stroke Education (STK-8)	STK	The Joint Commission		CMS Hospital Compare
Thrombolytic Therapy (STK-4)	STK	The Joint Commission	437	CMS Hospital Compare
VTE Prophylaxis (STK-1)	STK	The Joint Commission	434	CMS Hospital Compare
Hospital Acquired Potentially-Preventable VTE (VTE-6)	VTE	The Joint Commission		CMS Hospital Compare
ICU VTE Prophylaxis (VTE-2)	VTE	The Joint Commission	372	CMS Hospital Compare
VTE Patients w/Anticoagulation (VTE-3 )	VTE	The Joint Commission	373	CMS Hospital Compare
VTE Prophylaxis (VTE-1)	VTE	The Joint Commission	371	CMS Hospital Compare
VTE Warfarin Therapy Discharge Instructions (VTE-5 )	VTE	The Joint Commission		CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following acute ischemic stroke hospitalization		CMS		CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following AMI hospitalization		CMS	505	CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following CABG surgery		CMS	2515	CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following COPD hospitalization		CMS	1891	CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following heart failure (HF) hospitalization		CMS	330	CMS Hospital Compare
30-day all-cause risk-standardized readmission rate following pneumonia hospitalization		CMS	506	CMS Hospital Compare
30-day all-cause risk-standardized readmission rate RSRR following elective primary THA and/or TKA		CMS	1551	CMS Hospital Compare
American College of Surgeons Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site (SSI) Outcome Measure		CDC	753	CMS Hospital Compare
AMI 30-day mortality rate (risk-adjusted)		CMS	230	CMS Hospital Compare
Aortic Valve Replacement		Leapfrog Group		Leapfrog
Computerized physician order entry standards		Leapfrog Group		Leapfrog
DVT Prophylaxis in Women Undergoing Cesarean Section		Hospital Corporation of America	473	Leapfrog
Heart failure 30-day mortality rate for patients 18 and older (risk-adjusted)		CMS	229	CMS Hospital Compare
Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)		CMS	1789	HDD
Incidence of Episiotomy		Christiana Care Health System	470	Leapfrog
National Healthcare Safety Network (NHSN) Hospital-onset methicillin resistant staphylococcus bacteremia aureus (MRSA)		CDC	1716	CMS Hospital Compare
National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infections		CDC	138	CMS Hospital Compare
National Healthcare Safety Network (NHSN) Central-Line Associated Bloodstream Infection		CDC	139	CMS Hospital Compare
National Healthcare Safety Network (NHSN) Hospital-onset C. difficile		CDC	1717	CMS Hospital Compare
Newborn Bilirubin Screening		Leapfrog Group		Leapfrog
Pneumonia 30-day mortality rate (risk-adjusted)		CMS	468	CMS Hospital Compare
Survival Predictor for Pancreatic Resection Surgery		Leapfrog Group	738	Leapfrog
Timely transmission of transition record (CCM 3)		AMA-PCPI	648

Post-Acute Measures

Measure/Tool Name	Set	Steward	NQF #	Data Source for CHIA Reporting
Hospice and Palliative Care Dyspnea Screening*	HIS	UNC Chapel Hill	1639
Hospice and Palliative Care Pain Assessment*	HIS	UNC Chapel Hill	1637
Hospice and Palliative Care Beliefs/Values Addressed*	HIS	Deyta, LLC	1647
Hospice and Palliative Care Dyspnea Treatment*	HIS	UNC Chapel Hill	1638
Hospice and Palliative Care Pain Screening*	HIS	UNC Chapel Hill	1634
Hospice and Palliative Care Treatment Preferences*	HIS	UNC Chapel Hill	1641
Percent of High Risk Residents with Pressure Ulcers (Long Stay) (risk-adjusted)	Minimum Data Set (MDS)	CMS	679	CMS Nursing Home Compare
Percent of Residents Who Self-Report Moderate to Severe Pain (Long-Stay) (risk-adjusted)	Minimum Data Set (MDS)	CMS	677	CMS Nursing Home Compare
Percent of Residents Who Self-Report Moderate to Severe Pain (Short-Stay)	Minimum Data Set (MDS)	CMS	676	CMS Nursing Home Compare
Percent of Residents with Pressure Ulcers That Are New or Worsened (Short-Stay) (risk-adjusted)	Minimum Data Set (MDS)	CMS	678	CMS Nursing Home Compare
Acute care hospitalization (risk-adjusted)	OASIS	CMS	171	CMS Home Health Compare
Emergency Department Use without Hospitalization (risk-adjusted)	OASIS	CMS	173	CMS Home Health Compare
Timely Initiation of Care	OASIS	CMS	526	CMS Home Health Compare
Advance Care Plan		AMA-PCPI/NCQA	326
Palliative and End of Life Care: Dyspnea Screening & Management		AMA-PCPI/NCQA
Proportion admitted to hospice for less than 3 days		American Society of Clinical Oncology	216

*May apply to care delivered in acute and non-acute settings

Measures removed from the 2016 SQMS

Twelve measures were removed from the SQMS during the 2016 update:

Measures retired from 2015 HEDIS

Glaucoma screening for older adults
Cholesterol management for patients with cardiovascular conditions

Measures retired by CMS or provider data submission to CMS is now voluntary

Prophylactic antibiotic received within 1-hour prior to surgical incision (SCIP-Inf-1a)
Prophylactic antibiotic selection for surgical patients (SCIP-Inf-2a)
Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero (SCIP-Inf-9)
Surgery Patients with Perioperative Temperature Management (SCIP-Inf-10)
Surgery patients with recommended venous thromboembolism prophylaxis ordered (SCIP-VTE-1)
Initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent patients (PN 6)
Aspirin prescribed at discharge for AMI (AMI 2)
Primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival (AMI 8a)
Statin prescribed at discharge (AMI 10)

Measures that do not apply to the current uses of the SQMS (provider quality reporting, and provider tiering)

HEDIS Health Plan All-Cause Readmission measure

SQMS Archive

Older versions of the SQMS are available below:

2015 SQMS