June 15, 2009
Quality Measures Inventory by Basket of Care Topic
This is the inventory of measures relevant to each basket of care topic although some measures will need to be modified to more closely
align with the topic’s scopes and care components.
BofC Topic
Diabetes
Measure Title
1. Diabetes: Eye Exam
Measure Description
Type of Measure
Percentage of adult patients Process
with diabetes aged 18-75
years who received a
dilated eye exam or seven
standard field stereoscopic
photos with interpretation
by an ophthalmologist or
optometrist or imaging
validated to match
diagnosis from these photos
during the reporting year,
or during the prior year, if
patient is at low risk** for
retinopathy
**Patient is considered low
risk if the following
criterion is met: has no
evidence of retinopathy in
the prior year
Measure Source
NCQA (NQF endorsed)
2. Adult Diabetes:
Funduscopic Photo
Percentage of patients
Process
receiving a funduscopic
photo with interpretation by
an ophthalmologist or
optometrist
National Diabetes Quality
Improvement Alliance
1
3. Adult Diabetes: Eye Exam
Percentage of patients
receiving a dilated retinal
eye exam by an
ophtalmologist or
optometrist
Process
National Diabetes Quality
Improvement Alliance
4. Adult Diabetes: Retinopathy Percentage of patients who
received a dilated eye
examination or evaluation
of retinal photographs if
patient is at low risk for
retinopathy
Process
National Diabetes Quality
Improvement Alliance
5. Diabetes: Foot Exam
Percentage of adult patients
with diabetes aged 18-75
years who received a foot
exam (visual inspection,
sensory exam with
monofilament, or pulse
exam)
Process
NCQA (NQF endorsed)
6. Adult Diabetes: Foot Exam
Percentage of eligible
patients receiving at least
one foot exam, defined in
any manner
Process
National Diabetes Quality
Improvement Alliance
7. Adult Diabetes: Complete
Foot Exam
Percentage of patients
receiving at least one
complete foot examination
Process
National Diabetes Quality
Improvement Alliance
2
(visual inspection, sensory
exam with monofilament,
and pulse exam)
8. Hemoglobin A1c testing
Percentage of adult patients Process
with diabetes aged 18-75
years receiving one or more
A1c test(s) per year
NCQA (NQF endorsed)
9. Adult Diabetes:
Hemoglobin A1c testing
Percentage of patients
receiving one or more A1c
test(s)
Process
National Diabetes Quality
Improvement Alliance
10. Hemoglobin A1c
management
Percentage of adult patients
with diabetes aged 18-75
years with most recent A1c
level greater than 9.0%
(poor control)
Intermediate outcome
NCQA (NQF endorsed)
11. Hemoglobin A1c Control
Percentage of patients with
most recent A1c level
greater than 9.0% (poor
control)
Outcome
National Diabetes Quality
Improvement Alliance
12. Diabetes: Blood Pressure
Management
Percentage of patient visits
with blood pressure
measurement recorded
among all patient visits for
patients aged > 18 years
Process
NCQA (NQF endorsed)
3
with diagnosed
hypertension.
13. Blood Pressure Control
Percentage of patients with
most recent blood pressure
less than 140/90 mm Hg
Outcome
National Diabetes Quality
Improvement Alliance
14. Diabetes: Urine protein
screening
Percentage of adult diabetes Process
patients aged 18-75 years
with at least one test for
microalbumin during the
measurement year or who
had evidence of medical
attention for existing
nephropathy (diagnosis of
nephropathy or
documentation of
microalbuminuria or
albuminuria)
NCQA (NQF endorsed)
15. Adult Diabetes:
Microalbuminuria
Percentage of patients who
received any test for
microalbuminuria
Process
National Diabetes Quality
Improvement Alliance
16. Microalbumin Testing
Percentage of patients with
no urinalysis or urinalysis
with negative or trace urine
protein, who received a test
for microalbumin
Process
National Diabetes Quality
Improvement Alliance
4
17. Nephropathy Assessment
Percentage of patients with
at least one test for
micoalbumin during the
measurement year; or who
had evidence of medical
attention for existing
nephropathy (diagnosis of
nephropathy or
documentation of
microalbuminuria or
albuminuria)
Process
National Diabetes Quality
Improvement Alliance
18. Diabetes: Lipid profile
Percentage of adult patients
with diabetes aged 18-75
years receiving at least one
lipid profile (or ALL
component tests)
Process
NCQA (NQF endorsed)
19. Adult Diabetes: Lipids
Percentage of patients Process
receiving at least one lipid
profile (or all component
tests)
National Diabetes Quality
Improvement Alliance
20. Lipid testing
Percentage of patients with
at least one LDL-C test
National Diabetes Quality
Improvement Alliance
Process
5
21. Diabetes Measure Pair: A
Lipid management: low density
lipoprotein cholesterol (LDLC) <130, B Lipid management:
LDL-C <100
Percentage of adult patients
with diabetes aged 18-75
years with most recent
(LDL-C) <130 mg/dL
B: Percentage of patients
18-75 years of age with
diabetes whose most recent
LDL-C test result during
the measurement year was
<100 mg/dL
Intermediate Outcome
NCQA (NQF endorsed)
22.Comprehensive Diabetes
Care (CDC)
The percentage of patients
18-75 years of age with
diabetes (type 1 and type 2)
who had each of the
following:
• Hemoglobin A1c
(HbA1c) testing
• Hb1c poor control
(>9.0%)
• HbA1c control
(<8.0%)
• HbA1c control (<7.0%)
• Eye exam (retinal)
performed
• LDL-C screening
• LDL-C control
(<100mg/dL)
• Medical attention for
nephropathy
• Blood pressure control
(<130/80 mm Hg)
Outcome
NCQA
6
•
23. Optimal Diabetes Care
Blood pressure control
(<140/90 mm Hg)
Percentage of patients with
diabetes ages 18-75 who
reach all 5 treatment goals:
1. HbA1c<8
2. Blood Pressure
<130/80
3. LDL<100
4. Daily Aspirin Use
5. Documented
Tobacco Free
24. Relative resource use for
people with diabetes
Outcome
MNCM
Cost
NCQA
25. Adult Diabetes: Influenza
Immunization
Percentage of patients who
received an influenza
immunization during the
recommended calendar
period
Process
National Diabetes Quality
Improvement Alliance
26. Adult Diabetes: Smoking
Status
Percentage of patients
assessed for smoking status
Process
National Diabetes Quality
Improvement Alliance
7
Preventive CareChildren
27. Smoking Status and
Documentation
Percentage of patients for
whom smoking status was
ascertained and
documented annually
Process
National Diabetes Quality
Improvement Alliance
28. Pharmacologic Therapy
Counseling
Percentage of smokers who
were recommended or
offered an intervention for
smoking cessation (i.e.
counseling or
pharmacologic therapy)
Process
National Diabetes Quality
Improvement Alliance
1. CAHPS Clinician/Group
Surveys - (Adult Primary Care,
Pediatric Care, and Specialist
Care Surveys)
Access: Getting appointments
and health care when needed
Getting appointments for urgent
care; Getting appointments for
routine care or check-up; Getting
an answer to a medical question
during regular office hour;
Getting an answer to a medical
question after regular office
hours; Wait time for appointment
to start
How well doctors communicate
Doctor explanations easy to
understand; Doctor listens
carefully; Doctor gives easy-tounderstand instructions; Doctor
knows important information
about medical history; Doctor
shows respect for what you have
to say; Doctor spends enough
time with you
Patient Experience
AHRQ (NQF endorsed)
8
Courteous and helpful office
staff
Clerks and receptionists were
helpful; Clerks and receptionists
treat you with courtesy and
respect
How people rated doctor
§ 0–10 rating of doctor
2.Promoting Healthy
Development Survey (PHDS)
43-item survey given to
parents of children ages 3
to 48 months that assesses
parent’s experience with
care for the provision of
preventive and
developmental services
consistent with American
Academy of Pediatrics and
Bright futures practice
guidelines.
Level of analysis:
Physician, office, medical
group, health plan,
community, state, national
and by child and parent
health and social economic
characteristics
Patient Experience
OHSU (NQF endorsed)
9
3. Body Mass Index (BMI) 2
through 18 years of age
Percentage children, 2
through 18 years of age,
whose weight is classified
based on BMI percentile
for age and gender
Process
National Initiative for
Children's Healthcare
Quality (NQF endorsed)
4. Tobacco exposure
prevention for infants and
children
Percentage of patients with
documented tobacco
exposure at the latest visit
Process
ICSI
5. Childhood Immunization
Status
Percentage of children 2
years of age who had four
DtaP/DT, three IPV, one
MMR, three H influenza
type B, three hepatitis B,
one chicken pox vaccine
(VZV, four pneumococcal
conjugate vaccines, one
hepatitis A, one rotavirus
and influenza vaccines by
their second birthday. The
measure calculates a rate
for each vaccine and one
combination rate.
Process
NCQA (NQF endorsed)
6. Lead Screening in Children
The percentage of children
2 years of age who had one
or more capillary or venous
lead blood tests for lead
Process
NCQA
10
poisoning by their second
birthday
Preventive CareAdults
7. Well-child visits in the first
15 months of life
6 well care visits (at least 2
weeks apart) with a PCP.
Must show the evidence of
following: 1) health and
development history
(physical and mental), 2)
physical exam, 3) health
education/anticipatory
guidance
Access
NCQA
8. Vision impairment
screening
Percentage of children age
four years and younger
with documentation of
vision impairment
screening in the medical
record
Process
ICSI
9. Counseling for Nutrition
and Physical Activity
Percentage of patients 2-17 Process
years of age who had an
outpatient office visit and
who had evidence of BMI
percentile assessment,
counseling for nutrition and
physical activity during the
measurement year
Access: Getting appointments
Patient Experience
1. CAHPS Clinician/Group
Surveys - (Adult Primary Care,
Pediatric Care, and Specialist
Care Surveys)
and health care when needed
Getting appointments for urgent
care; Getting appointments for
routine care or check-up; Getting
an answer to a medical question
NCQA
AHRQ (NQF endorsed)
11
during regular office hour;
Getting an answer to a medical
question after regular office
hours; Wait time for appointment
to start
How well doctors communicate
Doctor explanations easy to
understand; Doctor listens
carefully; Doctor gives easy-tounderstand instructions; Doctor
knows important information
about medical history; Doctor
shows respect for what you have
to say; Doctor spends enough
time with you
Courteous and helpful office
staff
Clerks and receptionists were
helpful; Clerks and receptionists
treat you with courtesy and
respect
How people rated doctor
§ 0–10 rating of doctor
2. Blood pressure
measurement
Percentage of patient visits
with blood pressure
measurement recorded
among all patient visits for
patients aged > 18 years
with diagnosed
hypertension.
Process
American Medical
Association, NYU School
of Medicine (NQF
endorsed)
3. Hypertension Plan of Care
Percentage of patient visits
during which either systolic
blood pressure >= 140 mm
Hg or diastolic blood
pressure >= 90 mm Hg,
Process
American Medical
Association, NYU School
of Medicine (NQF
endorsed)
12
with documented plan of
care for hypertension.
4. Blood Pressure
Documentation
Percentage of adult patients Process
with blood pressure
documented in their
medical record (every two
years if less than 120/80;
every year if 120-139/80-89
Hg)
ICSI
5. Controlling High Blood
Pressure
Percentage of patients with
last BP < 140/80 mm Hg.
Intermediate Outcome
Centers for Medicare and
Medicaid Services,
National Committee for
Quality Assurance (NQF
endorsed)
6. Body Mass Index (BMI) in
adults > 18 years of age
Percentage of adults with
BMI documentation
Process
NCQA (NQF endorsed)
7. Smoking Cessation,
Medical assistance: a. Advising
Smokers to Quit, b. Discussing
Smoking Cessation
Medications, c. Discussing
a) Percentage of patients
who received advice to quit
smoking
Process
AMA (NQF endorsed)
b) Percentage of patients
13
Smoking Cessation Strategies
whose practitioner
recommended or discussed
smoking cessation
medications
c) Percentage of patients
whose practitioner
recommended or discussed
smoking cessation methods
or strategies
8. Measure pair: a. Tobacco
Use Assessment, b. Tobacco
Cessation Intervention
a) Percentage of patients
who were queried about
tobacco use one or more
times during the two-year
measurement period
Process
NCQA (NQF endorsed)
b) Percentage of patients
identified as tobacco users
who received cessation
intervention during the twoyear measurement period
9. Counseling on physical
activity in older adults - a.
Discussing Physical Activity,
b. Advising Physical Activity
Process
a) Percentage patients 65
years of age and older who
reported: discussing their
level of exercise or physical
activity with a doctor or
other health provider in the
last 12 months
b) Percentage patients 65
years of age and older who
reported receiving advice to
Centers for Medicare and
Medicaid Services,
National Committee for
Quality Assurance (NQF
endorsed)
14
start, increase, or maintain
their level of exercise or
physical activity from a
doctor or other health
provider in the last 12
months
10. Breast Cancer Screening
Percentage of eligible
women 50-69 who receive
a mammogram in a two
year period
Process
NCQA (NQF endorsed)
11. Cervical Cancer Screening
Percentage of women 18-64 Process
years of age, who received
one or more Pap tests
during the measurement
year or the two years prior
to the measurement year
NCQA (NQF endorsed)
12. Chlamydia Screening in
Women
Percentage of 16-25
Process
asymptomatic adult female
patients who were
identified as sexually active
who had at least one test for
chlamydia during the
measurement year
NCQA (NQF endorsed)
13. Colorectal Cancer
Screening
Percentage of adults 50-80
years of age who had
appropriate screening for
colorectal cancer (CRC)
NCQA (NQF endorsed)
Process
15
including fecal occult blood
test during the
measurement year or,
flexible sigmoidoscopy
during the measurement
year or the four years prior
to the measurement year or,
double contrast barium
enema during the
measurement year or the
four years prior to the
measurement year or,
colonoscopy during the
measurement year or the
nine years prior to the
measurement year
14. Annual dental visit
Annual dental preventive
care visit
Access
NCQA
15. Cancer Screening
Combined
Percentage of adults ages
51-80 who received
appropriate cancer
screening services (breast,
cervical, colorectal)
Process
MNCM
16. Aspirin counseling
Percentage of adult patients
with documentation in their
medical record indicating
aspirin chemoprophylaxis
Process
ICSI
16
counseling was provided
17. Alcohol abuse screening
Percentage of adult patients
with documentation of in
their medical record
indicating alcohol abuse,
hazardous and harmful
drinking screening was
performed.
Process
ICSI
18. Tobacco cessation
Percentage of adult patients
who are tobacco users with
documentation in their
medical record indicating,
“advise to quit” smoking
was provided at the most
recent visit.
Process
ICSI
19. Vision Screening
Percentage of
asymptomatic adult
patients, age 65 and older,
with documentation in their
medical record indicating
vision screening was
performed.
Process
ICSI
20. Adult access to
preventive/ambulatory care
Percentage of patients ages
20 and over who had an
annual ambulatory or
preventive care visit.
Access
NCQA
17
Asthma-Children
1. Asthma assessment
Percentage of patients who
were evaluated during at
least one office visit for the
frequency (numeric) of
daytime and nocturnal
asthma symptoms
Process
American Medical
Association - Physician
Consortium for
Performance
Improvement (NQF
endorsed)
2. Management plan for people Percentage of patients for
with asthma
whom there is
documentation that a
written asthma
management plan was
provided either to the
patient or the patient’s
caregiver OR, at a
minimum, specific written
instructions on under what
conditions the patient’s
doctor should be contacted
or the patient should go to
the emergency room
Process
IPRO (NQF endorsed)
3. Use of appropriate
medications for people with
asthma
Percentage of patients who Process
were identified as having
persistent asthma during the
measurement year and the
year prior to the
measurement year and who
were dispensed a
prescription for either an
inhaled corticosteroid or
acceptable alternative
medication during the
NCQA (NQF endorsed)
18
measurement year
4. Asthma: pharmacologic
therapy
Percentage of all patients
with mild,moderate, or
severe persistent asthma
who were prescribed either
the preferred long-term
control medication (inhaled
corticosteroid) or an
acceptable alternative
treatment
5. Relative resources use for
people with asthma
Process
AMA (NQF endorsed)
Cost
NCQA
Process
Joint Commission
6. Home Management Plan of
care (HPMC) document given
to patient/caregiver
An assessment there is
documentation in the
medical record that a home
management plan of care
(HPMC) document was
given to the pediatric
asthma patient/caregiver
7. Asthma care
Percentage of patients with Process
an asthma diagnosis
(defined as one repeat
prescription of a beta 2agonist in the past year)
who filled a prescription for
medications recommended
Manitoba Centre for
Health Policy
19
for long-term control of
asthma (i.e. inhaled
corticosteroids or
leukotriene modifiers, and
alternate anti-inflammatory
medication)
8. School Days Lost
Average number of lost
school days in the past 30
days
Outcome
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
9. Symptom-free Days
Average number of
symptom-free days in the
previous two weeks
Outcome
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
10. Environmental Triggers
Evaluation
Percentage of patients
evaluated for
environmental triggers
other than environmental
tobacco smoke (dust mites,
cats, dogs, molds/fungi,
cockroaches) either by
history of exposure and/or
by allergy testing
Process
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
11. Asthma Patients with
“Personal Best” Peak Flow
Percentage of patients older Outcome
than 5 years with moderate
or severe persistent asthma
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
20
who have established a
“personal best” peak flow
12. Influenza Immunization
Percentage of patients who Process
have a record of influenza
immunization in the past 12
months
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
13. Tobacco Smoke Exposure
Percentage of patients with
a reported exposure to
environmental tobacco
smoke at last visit
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
14. Asthma Severity
Assessment
Percentage of patients with Process
a severity assessment at last
contact (visit or phone)
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
15. Self-Management Goals
Percentage of patients with
documented selfmanagement goals in the
last 12 months
Process
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
16. Asthma Patients on
Medications
Percentage of patients with
persistent asthma at last
contact who are on an antiinflammatory medication
Process
HRSA Health Disparities
Collaboratives: Asthma
Collaborative
Outcome
21
17. Medication Prescription
Percentage of patients 5-56
years of age during the
measurement year who
were identified as having
persistent asthma and who
were appropriately
prescribed medication
during the measurement
year
Process
NCQA
18. Spirometry or Peak Flow
Documentation
Percentage of patients with
asthma with spirometry or
peak flow documented at
the last visit
Process
ICSI
19. Home Peak Flow Meter
Usage
Percentage of patients with
asthma, for whom a peak
flow meter is appropriate,
who report using a home
peak flow meter
Process
ICSI
20.AsthmaSeverity Assessment
Percentage of patients with
asthma with severity
assessment using a
validated questionnaire
Process
ICSI
21. Corticosteroid Medication
Percentage of patients with
uncontrolled asthma who
are on inhaled
Process
ICSI
22
corticosteroid medication
22. Asthma Action Plan
Percentage of patients with
asthma with an asthma
action plan in the medical
record
Process
ICSI
23. Asthma Education
Percentage of patients with
asthma with education
about asthma documented
in the medical record
Process
ICSI
24. Peak Flow Measurement
Documentation
Percentage of patients with Process
asthma who have
documentation of peak flow
measurement during the
initial assessment
ICSI
25. Asthma Severity
Exacerbation
Percentage of patients with Process
any assessment of asthma
severity documented during
the initial assessment
ICSI
26. Appropriate Treatment
Percentage of patients with
diagnosed asthma who
receive appropriate
treatment as rapidly as
possible based on response
Process
ICSI
27. Asthma Control
Percentage of asthma
patients who are
Process
ICSI
23
uncontrolled or have a
change in medication or
clinical status, who are seen
by a health care provider
within two to six weeks
OB Care
28. Asthma Controlled
Percentage of stable
patients who are seen by a
health care provider every
one to six months
Process
ICSI
1. Prenatal Blood Group
Antibody Testing
Percentage of patients who
gave birth during a 12month period who were
screened for blood group
antibodies during the first
or second prenatal care
visit.
Process
AMA (NQF endorsed)
2. Prenatal Blood Groups
(ABO), D (Rh) Type
Percentage of patients who
gave birth during a 12month period who had a
determination of blood
group (ABO) and D (Rh)
type by the second prenatal
care visit.
Process
AMA (NQF endorsed)
3. Prenatal Screening for
Human Immunodeficiency
Virus (HIV)
Percentage of patients who
gave birth during a 12month period who were
screened for HIV infection
during the first or second
prenatal care visit.
Process
AMA (NQF endorsed)
24
4. HIV Testing and Screening
Percentage of pregnant
women with counseling
offered and testing
performed during the
prenatal period
Process
New York State
Department of Health
AIDS Institute
5. Frequency of ongoing
prenatal care
Prenatal visit within first
trimester (or within 42 days
of enrollment)
Process
NCQA
6. VBAC
Prenatal patient evaluation,
management, and treatment
selection concerning
vaginal deliveries in
patients who have a history
of previous cesarean
section
Outcome
Joint Commission
7. Routine Prenatal Care
Percentage of pregnant
women who report to have
received counseling and
education by the 28th week
visit
Process
ICSI
8. Routine prenatal care
Percentage of all identified
preterm birth (PTB)
modifiable risk factors
assessed that receive an
intervention
Process
ICSI
25
9. Routine prenatal care
Percentage of vaginal birth
after cesearean (VBAC)
eligible women who
receive general education
describing risks and
benefits of VBAC (e.g. the
American College of
Obstetricians and
Gynecologists pamphlet on
VBAC)
Process
ICSI
10. Timeliness of prenatal care
Percentage of deliveries
Process
that received a prenatal care
visit as a member of the
organization in the first
trimester or within 42 days
of enrollment in the
organization
NCQA
11. Frequency of ongoing
prenatal care
Percentage of Medicaid
Process
deliveries between
November 6 of the year
prior to the measurement
year and November 5 of the
measurement year that
received less than 21%,
21%-40%, 41% -60%,
61%-80%, or greater than
or equal to 81% of the
expected number of
prenatal care visits
NCQA
26
12. Prenatal Care
Percentage of D (Rh)
negative, unsensitized
patients, regardless of age,
who gave birth during a 12month period who received
anti-D immune globulin at
26-30 weeks gestation
Process
AMA (PCPI)
13. Access to prenatal care
Time to third next available
appointment for physical
exam
Process
Wisconsin Collaborative
for Healthcare Quality
14. Domestic violence
screening
Percentage of healthcare
staff trained in initial
assessment of problems of
domestic violence every
twelve months
Process
ICSI
15. Screening for Risk Factors
Percentage of initial risk
Process
assessment forms
completed within two visits
of initiation of prenatal care
ICSI
16. Risk Factors Intervention Percentage of pregnant
Documentation
women with interventions
documented for identified
risk factors
Process
ICSI
27
17.PreconceptionRisk
Assessment/Counseling
Percentage of pregnant
women with documented
preconception risk
assessment and counseling
Process
ICSI
18. Aneuploidy Screening
Percentage of pregnant
women who receive
counseling about
aneuploidy screening in the
first trimester
Process
ICSI
19. VBAC Personal Risks and
Benefits Education
Percentage of VBACeligible women who
receive documented
education describing the
personal risks and benefits
of VBAC (e.g., two or
more previous Caesarean
deliveries)
Process
ICSI
20. VBAC Personal Risks and
Benefits Education
Percentage of VBACeligible women who can
describe the personal risks
and benefits of VBAC
Outcome
ICSI
21. Appropriate Intervention
for Women with preterm birth
(PTB) risk factors
Percentage of all identified
modifiable and nonmodifiable PTB risk factors
that receive appropriate
follow-up.
Process
ICSI
28
Low Back Pain
1. Low back pain: use of
imaging studies
Percentage of patients (18- Process
50) with new low back pain
who received an imaging
study (plain x-ray, MRI,
CT scan) conducted on the
episode start date or in the
28 days following the
episode start date
NCQA (NQF endorsed)
2. LBP: Advice Against
Bedrest
Percentage of patients with
medical record
documentation that a
physician advised them
against bed rest lasting four
days or longer.
Process
NCQA (NQF endorsed)
3. LBP: Advice for Normal
Activities
Percentage of patients with
medical record
documentation that a
physician advised them to
maintain or resume normal
activities.
Process
NCQA (NQF endorsed)
4. LBP: Appropriate Imaging Percentage of patients with
for Acute Back Pain
a diagnosis of back pain for
whom the physician
ordered imaging studies
during the six weeks after
pain onset, in the absence
of red flags (overuse
measure, lower
performance is better).
Process
NCQA (NQF endorsed)
29
5. LBP: Evaluation of Patient
Experience
Percentage of physician
mechanisms used to
evaluate patient experience
based on evidence of the
following. An ongoing
system for obtaining
feedback about patient
experience with care. A
process for analyzing the
data and a plan for
improving patient
experience. Note: This
standard is assessed as a
process that applies to all
patients. Evaluation is not
based on documentation in
individual medical records.
Patient Experience
NCQA (NQF endorsed)
6. LBP: Mental Health
Assessment
Percentage of patients with
a diagnosis of back pain for
whom documentation of a
mental health assessment is
present in the medical
record prior to intervention
or when pain lasts more
than six weeks.
Process
NCQA (NQF endosed)
7. LBP: Patient Education
Percentage of patients
provided with educational
materials that review the
natural history of the
disease and
Process
NCQA (NQF endorsed)
30
treatmenoptions, including
alternatives to surgery, the
risks and benefits and the
evidence.
Note: This standard is
assessed as a process that
applies to all patients.
Evaluation is not based on
documentation in
individual medical records.
8. LBP: Patient Reassessment
Percentage of patients with
documentation that the
physician conducted
reassessment of both of the
following. Pain, and
Functional status
Process
NCQA (NQF endorsed)
9. LBP: Physical Exam
Percentage of patients with Process
documentation of a
physical examination on the
date of the initial visit with
the physician.
NCQA (NQF endorsed)
10. LBP: Repeat Imaging
Studies
Percentage of patients who
received inappropriate
repeat imaging studies in
the absence of red flags or
progressive symptoms
(overuse measure, lower
performance is better).
NCQA (NQF endorsed)
Process
31
11. Relative resources use for
people with low back pain
Cost
NCQA
12. Adult low back pain
Percentage of low back
pain patients without red
flag indicators undergoing
anterior-posterior (AP) or
lateral (LAT) x-rays
Process
ICSI
13. Lumbar functional status
Mean change score in
lumbar functional status for
patients with lumber
impairments receiving
physical rehabilitation
Outcome
Focus on Therapeutic
Outcomes
14. Low Back Pain Initial Visit Percentage of patients who Process
Documentation
have medical record
documentation of all of the
following on the date of
initial visit to the physician:
1. Pain Assessment
2. Functional Status
3. Patient history
including notation
of presence or
absence of “red
flags”
4. Assessment of prior
treatment and
NCQA
32
response
5. Employment status
6. Psychosocial
screening that
includes depression
and chemical
dependency
screening
15. Follow up Documentation
Percentage of patients with
documentation in the
medical record of a
reassessment at each
follow-up visit that
includes:
1. Pain assessment
(subjective pain
rating)
2. Functional
assessment
3. Clinican’s objective
assessment
4. Psychosocial
screening that
includes depression
and chemical
dependency
screening
Process
ICSI
33
16. LBP: Imaging Study
without “red flag” indicators
Percentage of patients with Process
acute pain without “red
flag” indicators who did not
receive an imaging study
(plain x-ray, MRI, CT scan)
within 28 days of the
diagnosis
ICSI
17. Inappropriate Repeat
Imaging Tests
Percentage of patients who
received inappropriate
repeat imaging studies in
the absence of “red flags”
or progressive symptoms
Process
NCQA
18. Education Documentation
Percentage of patients with
documentation in the
medical record of patient
receiving education
regarding low back pain
self-care and the
importance of maintaining
an active lifestyle
Process
NCQA
34
Total Knee
Replacement
19.Treatment
Recommendations
Reinforcement
Percentage of patients Process
returning to their primary
care provider for one to
three-week follow up for
reinforcement of treatment
recommendations
ICSI
20. Analgesic Medication
Recommendation Follow up
Percentage of patients with
documentation in the
medical record of
recommendation to take an
anti-inflammatory or
analgesic medication.
Process
ICSI
21. Effectiveness of Care
Functional Status using
pain scale index
Outcome
1. Prophylactic Antibiotic after Prophylactic antibiotics
the Surgery
discontinued within 24
hours after surgery end
time-knee arthroplasty
Process
Recommended by the
Low Back Pain
Subcommittee
SCIP-Joint Commission
2. Prophylactic Antibiotic
Prior to Surgery
Process
SCIP-Joint Commission
Prophylactic antibiotic
received within one hour
prior to surgical incisionknee arthroplasty
35
3. Prophylactic Antibiotic
Selection
Prophylactic Antibiotic
Selection for surgical
patients consistent with
guidelines-knee
arthroplasty
Process
SCIP-Joint Commission
4. Hair Removal
Surgery patients with
appropriate hair removal
Process
SCIP-Joint Commission
5. VTE Prophylaxis Ordered
Surgery patients with
recommended VTE
Prophylaxis ordered
Process
SCIP-Joint Commission
6. Appropriate VTE
Prophylaxis
Surgery patients who
received appropriate VTE
Prophylaxis within 24
hours prior to surgery to 24
hours after surgery
Process
SCIP-Joint Commission
7. Perioperative care
Percentage of patients
undergoing procedures for
which VTE prophylaxis is
indicated in all patients
who had an order for lowmolecular weight heparin
(LMWH), low-dose
unfractioned heparin
(LDUH), adjusted-dose
warfarin, fondaparinuz or
Process
American College of
Surgeons, NCQA
36
mechanical prophylaxis to
be given within 24 hours
prior to incision time or 24
hours after surgery end
time
8. Prophylactic Antibiotic
under Current Guidelines
Percentage of patients who
received prophylactic
antibiotics consistent with
current guidelines
Process
CMS/Joint Commission
9. Superficial Incision
Percentage of superficial
incisional surgical site
infections (SSIs) in knee
prosthesis procedures
performed, during the 6
month period
Process
Australian Council on
Healthcare Standards
10. Deep Incision
Percentage of deep
incisional surgical site
infections (SSIs) in knee
prosthesis procedures,
during the 6 month time
period
Process
Australian Council on
Healthcare Standards
11. Antibiotic Indications
Percentage of surgical
Process
patients 18 and older
undergoing procedures with
the indications for a first or
second generation
cephalosporin prophylactic
antibiotic who had an order
American College of
Surgeons, NCQA
37
for cefazolin or cefuroxime
for antimicrobial
prophylaxis
12. VTE Prophylaxis
Assessment
Percentage of adult
hospitalized patients who
are assessed for VTE risk
within 24 hours of
admission
Process
ICSI
13. Hospital Readmissions for
VTE related conditions
Percentage of hospitalized
adult patients who require
hospital readmission within
30 days of discharge for
conditions related to VTE
Outcome
ICSI
14. Surgery Events
Wrong surgery events per
month
Outcome
ICSI
15. Near Misses
Near misses reported per
month
Outcome
ICSI
16. Retained Foreign Objects
Number of unintentionally
retained foreign objects in
surgery
Outcome
ICSI
38
17. Wound infection
Percentage of postoperative
wound infection in patients
undergoing clean surgery
Outcome
IHI
18. Perioperative Verification
Percentage of surgical
patients with
documentation of
preoperative verification of
patient, procedure, and
site/side level
Process
ICSI
19. Preoperative Site Marking
Percentage of appropriate
surgical patients who had
their site marked by the
surgeon in preop with
his/her initials
Process
ICSI
20. Verbal Active Timeout
Percentage of surgical cases Process
in which a verbal, active
time out has been
conducted by all members
of the surgical team prior to
incision
ICSI
21. Baseline Count
Percentage of surgical cases Process
where the baseline count
was conducted prior to the
patient arriving in the
ICSI
39
surgical suite
22. Imaging
Percentage of surgical cases Process
where counts were not
reconciled and imaging was
performed
ICSI
23. Components of the
Perioperative Protocol
Percentage of patients who
have had all the required
components of the
perioperative protocol
applied
Process
ICSI
24. H-CAHPS
Survey of patient’s hospital
experience:
Communication with
doctors; communication
with nurses; responsiveness
of hospital staff; pain
control; communication
about medicines;
cleanliness of hospital
environment; quietness of
hospital environment;
discharge instructions;
overall rating of the
hospital; willingness to
recommend the hospital to
others
Patient Experience
AHRQ (NQF endorsed)
40