2017 Standard Quality Measure Set

Physician/Group Measures

Measure/Tool Name	Set	NQF #	Data Source for CHIA Reporting
Consumer assessment of healthcare providers and systems (CAHPS) - clinician & group survey	CAHPS	5	MHQP
Therapeutic monitoring: Annual monitoring for patients on persistent medications	HEDIS	2371	MHQP
Use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD)	HEDIS	577
Controlling high blood pressure	HEDIS	18	MHQP
Comprehensive diabetes care	HEDIS		MHQP
Disease modifying anti-rheumatic drug therapy for rheumatoid arthritis	HEDIS	54
Osteoporosis management in women who had a fracture	HEDIS	53
Pharmacotherapy of chronic obstructive pulmonary disease (COPD) exacerbation	HEDIS	2856
Medication management for people with asthma	HEDIS	1799
Asthma medication ratio	HEDIS	1800	MHQP
Potentially harmful drug-disease interactions in the elderly	HEDIS
Avoidance of antibiotic treatment in adults with acute bronchitis	HEDIS	58	MHQP
Use of imaging studies for low back pain	HEDIS	52	MHQP
Use of high-risk medications in the elderly	HEDIS	22
Care for older adults - medication review	HEDIS	553
Persistence of beta-blocker treatment after a heart attack	HEDIS	71
Medication reconciliation post-discharge	HEDIS	554
Appropriate treatment for children with upper respiratory infection	HEDIS	69	MHQP
Well-child visits in the third, fourth, fifth and sixth years of life	HEDIS	1516	MHQP
Appropriate testing of children with pharyngitis	HEDIS		MHQP
Follow-up care for children prescribed ADHD medication	HEDIS	108	MHQP
Adolescent well-care visits	HEDIS		MHQP
Childhood immunization status	HEDIS	38
Immunizations for adolescents	HEDIS	1407
Lead screening in children	HEDIS
Weight assessment and counseling for nutrition and physical activity for children/adolescents	HEDIS	24
Children and adolescents' access to primary care practitioners	HEDIS
Frequency of ongoing prenatal care	HEDIS	1391
Prenatal and postpartum care	HEDIS	1517
Well-child visits in the first 15 months of life	HEDIS	1392	MHQP
Breast cancer screening	HEDIS	2372	MHQP
Colorectal cancer screening	HEDIS	34	MHQP
Cervical cancer screening	HEDIS	32	MHQP
Chlamydia screening in women	HEDIS	33	MHQP
Adult BMI assessment	HEDIS
Adults' access to preventive/ambulatory health services	HEDIS
Initiation and engagement of alcohol and other drug dependence treatment	HEDIS	4
Antidepressant medication management	HEDIS	105	MHQP
Follow-up after hospitalization for mental illness	HEDIS	576
Adherence to antipsychotics for individuals with schizophrenia	HEDIS	1879
Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications	HEDIS	1932
Diabetes monitoring for people with diabetes and schizophrenia	HEDIS	1934
Cardiovascular monitoring for people with cardiovascular disease and schizophrenia	HEDIS	1933
Non-recommended cervical cancer screening in adolescent females	HEDIS
Non-recommended PSA-based screening in older men	HEDIS
Use of multiple concurrent antipsychotics in children and adolescents	HEDIS
Metabolic monitoring for children and adolescents on antipsychotics	HEDIS	2800
Use of first-line psychosocial care for children and adolescents on antipsychotics	HEDIS	2801
Follow-up after emergency department visit for mental illness	HEDIS	2605
Follow-up after emergency department visit for alcohol or other drug dependence	HEDIS	2605
Depression remission or response for adolescents and adults	HEDIS
Statin therapy for patients with cardiovascular conditions	HEDIS
Statin therapy for patients with diabetes	HEDIS
Asthma in younger adults admission rate (PQI 15)	PQI	283	CHIA Hospital Discharge Database
Chronic obstructive pulmonary disease (COPD) or asthma in older adults admission rate (PQI 5)	PQI	275	CHIA Hospital Discharge Database
Heart failure admission rate (PQI 8)	PQI	277	CHIA Hospital Discharge Database
Diabetes short-term complications admission rate (PQI 1)	PQI	272	CHIA Hospital Discharge Database
Low birth weight rate (PQI 9)	PQI	278	CHIA Hospital Discharge Database
Screening for clinical depression and follow-up plan		418
Preventive care & screening: Tobacco use: Screening and cessation intervention	AMA-PCPI	28
Preventive care & screening: Unhealthy alcohol use: Screening & brief counseling	AMA-PCPI	2152
Asthma emergency department visits
Depression utilization of the PHQ-9 tool	MN Community Management	712
Maternal depression screening
Depression screening by 18 years of age

Hospital Measures

Measure/Tool Name	Set	NQF #	Data Source for CHIA Reporting
VTE prophylaxis (STK-1)	STK	434	CMS/Hospital Compare
Thrombolytic therapy (STK-4)	STK	437	CMS/Hospital Compare
Discharged on statin (STK-6)	STK	439	CMS/Hospital Compare
Stroke education (STK-8)	STK		CMS/Hospital Compare
VTE prophylaxis (VTE-1)	VTE	371	CMS/Hospital Compare
ICU VTE prophylaxis (VTE-2)	VTE	372	CMS/Hospital Compare
VTE patients w/anticoagulation (VTE-3 )	VTE	373	CMS/Hospital Compare
VTE Warfarin therapy discharge instructions (VTE-5 )	VTE		CMS/Hospital Compare
Hospital acquired potentially-preventable VTE (VTE-6)	VTE		CMS/Hospital Compare
Severe sepsis & septic shock: Management bundle (SEP-1)	SEP	500	CMS/Hospital Compare
Influenza immunization (IMM 2)	IMM	1659	CMS/Hospital Compare
Relievers for inpatient asthma (CAC 1)	CAC		CMS/Hospital Compare
Systemic corticosteroids for inpatient asthma (CAC 2)	CAC		CMS/Hospital Compare
Hospital-wide all-cause unplanned readmission measure (HWR)	Yale/CMS	1789	CHIA Hospital Discharge Database
Timely transmission of transition record (CCM 3)	AMA-PCPI	648
Fibrinolytic therapy received within 30 minutes of hospital arrival (AMI 7a)	AMI		CMS/Hospital Compare
Hospital consumer assessment of healthcare providers and systems (HCAHPS)	CAHPS	166/228	CMS/Hospital Compare
Computerized physician order entry standards			Leapfrog
Pressure ulcer rate (PSI 3)	PSI		CHIA Hospital Discharge Database
Iatrogenic pneumothorax rate (PSI 6)	PSI	346	CHIA Hospital Discharge Database
Central venous catheter-related blood stream infection rate (PSI 7)	PSI		CHIA Hospital Discharge Database
Post-operative respiratory failure rate (PSI 11)	PSI	533	CHIA Hospital Discharge Database
Perioperative pulmonary embolism or deep vein thrombosis (PE/DVT) rate (PSI 12)	PSI	450	CHIA Hospital Discharge Database
Unrecognized abdominopelvic accidental puncture or laceration rate (PSI 15)	PSI	345	CHIA Hospital Discharge Database
Post-operative hip fracture rate (PSI 8)	PSI		CHIA Hospital Discharge Database
Birth trauma rate: Injury to neonates (PSI 17)	PSI		CHIA Hospital Discharge Database
Obstetric trauma: Vaginal delivery with instrument (PSI 18)	PSI		CHIA Hospital Discharge Database
Obstetric trauma: Vaginal delivery without instrument (PSI 19)	PSI		CHIA Hospital Discharge Database
Patients discharged on multiple antipsychotic medications with appropriate justification (HBIPS 5)	HBIPS	560	CMS/Hospital Compare
Post-discharge continuing care plan transmitted to next level of care provider upon discharge (HBIPS 7)	HBIPS		CMS Hospital Compare
Post-discharge continuing care plan created (HBIPS 6)	HBIPS		CMS Hospital Compare
Elective deliveries (PC-01)	PC	469	Leapfrog
Cesarean section (PC-02)	PC	471	Leapfrog
Antenatal steroids (for high risk newborn deliveries) (PC-03)	PC	476	Leapfrog
Health care-associated bloodstream infections in newborns (PC-04)	PC	1731
Exclusive breast milk feeding (PC-05)	PC	480
Newborn bilirubin screening			Leapfrog
DVT prophylaxis in women undergoing cesarean section		473	Leapfrog
Incidence of episiotomy		470	Leapfrog
Aortic valve replacement			Leapfrog
Survival predictor for pancreatic resection surgery			Leapfrog
Patient safety composite (PSI 90)	PSI	531	CHIA Hospital Discharge Database
Pneumonia 30-day mortality rate (risk-adjusted)		468	CMS/Hospital Compare
Heart failure 30-day mortality rate for patients 18 and older (risk-adjusted)		229	CMS/Hospital Compare
AMI 30-day mortality rate (risk-adjusted)		230	CMS/Hospital Compare
National Healthcare Safety Network (NHSN) hospital-onset methicillin resistant staphylococcus bacteremia aureus (MRSA)		1716	CMS/Hospital Compare
National Healthcare Safety Network (NHSN) central-line associated bloodstream infection		139	CMS/Hospital Compare
National Healthcare Safety Network (NHSN) hospital-onset C. difficile		1717	CMS/Hospital Compare
National Healthcare Safety Network (NHSN) catheter-associated urinary tract infections		138	CMS/Hospital Compare
American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) harmonized prodcedure specific surgical site (SSI) outcome measure	CDC	753	CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate following AMI hospitalization		505	CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate following heart failure (HF) hospitalization		330	CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate following pneumonia hospitalization		506	CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate following acute ischemic stroke hospitalization			CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate following CABG surgery		2515	CMS/Hospital Compare
30-Day all-cause risk-standardized readmission rate following COPD hospitalization		1891	CMS/Hospital Compare
30-day all-cause risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA		1551	CMS/Hospital Compare

Post-Acute Measures

Measure/Tool Name	Set	NQF #	Data Source for CHIA Reporting
Acute care hospitalization (risk-adjusted)	OASIS	171	CMS/Home Health Compare
Emergency department use without hospitalization (risk-adjusted)	OASIS	173	CMS/Home Health Compare
Timely initiation of care	OASIS	526	CMS/Home Health Compare
Percent of residents with pressure ulcers that are new or worsened (short-stay) (risk-adjusted)	CMS – Minimum Data Set (MDS)	678	CMS/Nursing Home Compare
Percent of high risk residents with pressure ulcers (long stay) (risk-adjusted)	CMS – Minimum Data Set (MDS)	679	CMS/Nursing Home Compare
Percent of residents who self-report moderate to severe pain (short-stay)	CMS – Minimum Data Set (MDS)	676	CMS/Nursing Home Compare
Percent of residents who self-report moderate to severe pain (long-stay) (risk-adjusted)	CMS – Minimum Data Set (MDS)	677	CMS/Nursing Home Compare
Proportion admitted to hospice for less than 3 days		216
Advance care plan	AMA-PCPI/NCQA	326
Palliative and end of life care: Dyspnea screening & management
Hospice and palliative care – pain screening*	HIS	1634
Hospice and palliative care – pain assessment*	HIS	1637
Hospice and palliative care – Dyspnea screening*	HIS	1639
Hospice and palliative care – Dyspnea treatment*	HIS	1638
Hospice and palliative care – beliefs/values addressed*	HIS	1647
Hospice and palliative care – treatment preferences*	HIS	1641

*May apply to care delivered in acute and non-acute settingsMeasure Sets

Measure Sets

HEDIS: Healthcare Effectiveness Data and Information Set
PQI: Prevention Quality Indicators
HF: Heart Failure
PSI: Patient Safety Indicators
CAC: Children’s Asthma Care
AMI: Acute Myocardial Infarction
SCIP: Surgical Care Improvement Project
CAHPS: The Consumer Assessment of Healthcare Providers and Systems
OASIS: Outcome and Assessment Information Set
AMA-PCPI: AMA’s Physician Consortium for Performance Improvement
HBIPS: Hospital-based Inpatient Psychiatric Services
HIS: Hospice Item Set
PC: Perinatal Care

Measures removed from the SQMS in 2017

Twenty-one measures were removed from the SQMS during the latest update:

Measures retired from 2017 HEDIS

Use of appropriate medications for people with asthma
Human Papillomavirus vaccine for female adolescents Measures retired by CMS or provider data submission to CMS is now voluntary
Evaluation of Left Ventricular Systolic (LVS) Function (HF-2)
Surgery patients on beta-blocker therapy prior to arrival who received beta-blocker during the perioperative period (SCIP-Card-2)
Prophylactic antibiotics discontinued within 24 hours after surgery end time (SCIP-Inf-3a)
Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery (SCIP-VTE-2)
Cardiac surgery patients with controlled postoperative blood glucose (SCIP-Inf-4)
Home management plan of care document given to patient/caregiver (CAC-3)
Detailed discharge instructions (HF-1)
Patients discharged on multiple antipsychotic medications (HBIPS-4)

HEDIS Measures removed to align SQMS with HEDIS Physician Measure set

Annual dental visit
Aspirin use and discussion
CAHPS Health Plan Survey v 3.0 children with chronic conditions supplement
Counseling on physical activity in older adults
Fall risk management
Flu shots for adults ages 18-64
Flu shots for adults ages 65 and older
Medical assistance with smoking and tobacco use cessation
Osteoporosis testing in older women
Pneumococcal vaccination status for older adults
Urinary incontinence management in older adults

SQMS Archive

Older versions of the SQMS are available below: