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Standard Quality Measure Set (SQMS) Resources
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. CHIA's Executive Director 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.
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.
CHIA has also compiled a list of measures to display the breadth of quality measurement in the Commonwealth in the 2016 Quality Measure Catalog (Excel).
|
Measure/Tool Name
|
Set
|
NQF #
|
CHIA Data Source(s)
|
Data Reported by CHIA
|
Notes
|
|
Consumer assessment of healthcare providers and systems (CAHPS) - clinician & group survey
|
CAHPS
|
5
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Child consumer assessment of healthcare providers and hospital systems (Child HCAHPS)
|
CAHPS
|
2548
|
Added to SQMS in 2018 | ||
|
Therapeutic monitoring: Annual monitoring for patients on persistent medications
|
HEDIS
|
2371
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD)
|
HEDIS
|
577
|
|||
|
Controlling high blood pressure
|
HEDIS
|
18**
|
MHQP was CHIA data source for data prior to 2017 | ||
|
Comprehensive diabetes care
|
HEDIS
|
X
|
NQF endorsement dropped (formerly #731) MHQP was CHIA data source for data prior to 2017 |
||
|
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
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Potentially harmful drug-disease interactions in the elderly
|
HEDIS
|
||||
|
Avoidance of antibiotic treatment in adults with acute bronchitis
|
HEDIS
|
58
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Use of imaging studies for low back pain
|
HEDIS
|
52
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Use of high-risk medications in the elderly
|
HEDIS
|
22
|
|||
|
Care for older adults - advance care planning, medication review, functional status assessment, & pain assessment
|
HEDIS
|
553
|
NQF endorsement refers only to medication review portion of this measure | ||
|
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
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Well-child visits in the third, fourth, fifth and sixth years of life
|
HEDIS
|
1516
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Appropriate testing of children with pharyngitis
|
HEDIS
|
X
|
NQF endorsement dropped (formerly #2) MHQP was CHIA data source for data prior to 2017 |
||
|
Follow-up care for children prescribed ADHD medication
|
HEDIS
|
108
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Adolescent well-care visits
|
HEDIS
|
X
|
MHQP was CHIA data source for data prior to 2017 | ||
|
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
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Breast cancer screening
|
HEDIS
|
2372
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Colorectal cancer screening
|
HEDIS
|
34
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Cervical cancer screening
|
HEDIS
|
32
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
Chlamydia screening in women
|
HEDIS
|
33
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
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
|
X
|
MHQP was CHIA data source for data prior to 2017 | |
|
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
|
X
|
|
|
Chronic obstructive pulmonary disease (COPD) or asthma in older adults admission rate (PQI 5)
|
PQI
|
275
|
CHIA Hospital Discharge Database
|
X
|
|
|
Heart failure admission rate (PQI 8)
|
PQI
|
277
|
CHIA Hospital Discharge Database
|
X
|
|
|
Diabetes short-term complications admission rate
(PQI 1) |
PQI
|
272
|
CHIA Hospital Discharge Database
|
X
|
|
|
Low birth weight rate (PQI 9)
|
PQI
|
278
|
CHIA Hospital Discharge Database
|
X
|
|
|
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
|
NQF endorsement removed (formerly #1381) | ||||
|
Depression utilization of the PHQ-9 tool
|
MN Community Management
|
712
|
|||
|
Maternal depression screening
|
NQF endorsement removed (formerly #1401) | ||||
|
Depression screening by 18 years of age
|
NQF endorsement removed (formerly #1515) |
|
Measure/Tool Name
|
Set
|
NQF #
|
CHIA Data Source(s)
|
Data Reported by CHIA
|
Notes
|
|
VTE Warfarin therapy discharge instructions (VTE-5 )
|
VTE
|
CMS/Hospital Compare
|
X
|
NQF endorsement removed (formerly #375) | |
|
Hospital acquired potentially-preventable VTE (VTE-6)
|
VTE
|
CMS/Hospital Compare
|
X
|
NQF endorsement removed (formerly #376) | |
|
Severe sepsis & septic shock: Management bundle (SEP-1)
|
SEP
|
500
|
CMS/Hospital Compare
|
||
|
Influenza immunization (IMM 2)
|
IMM
|
1659
|
CMS/Hospital Compare
|
X
|
|
|
Relievers for inpatient asthma (CAC 1)
|
CAC
|
CMS/Hospital Compare
|
X
|
NQF endorsement removed (formerly #143) | |
|
Systemic corticosteroids for inpatient asthma (CAC 2)
|
CAC
|
CMS/Hospital Compare
|
X
|
NQF endorsement removed (formerly #144) | |
|
Median time to transfer to another facility for acute coronary intervention (OP 3)
|
OP
|
290
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
Aspirin at arrival (OP 4)
|
OP
|
CMS/Hospital Compare
|
Added to SQMS in 2018 NQF endorsement removed (formerly #286) |
||
|
Thorax CT - use of contrast material (OP 11)
|
OP
|
513
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
Cardiac imaging for perioperative risk assessment for non-cardiac, low risk surgery (OP 13)
|
OP
|
669
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
Hospital-wide all-cause unplanned readmission measure (HWR)
|
Yale/CMS
|
1789
|
CHIA Hospital Discharge Database
|
X
|
|
|
Pediatric all-condition readmission measure
|
2393
|
CHIA Hospital Discharge Database
|
Added to SQMS in 2018 | ||
|
Timely transmission of transition record (CCM 3)
|
AMA-PCPI
|
648
|
|||
|
Hospital consumer assessment of healthcare providers and systems (HCAHPS)
|
CAHPS
|
166/228
|
CMS/Hospital Compare
|
X
|
|
|
Computerized physician order entry standards
|
Leapfrog
|
X
|
|||
|
Pressure ulcer rate (PSI 3)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Iatrogenic pneumothorax rate (PSI 6)
|
PSI
|
346
|
CHIA Hospital Discharge Database
|
X
|
|
|
Central venous catheter-related blood stream infection rate (PSI 7)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Post-operative respiratory failure rate (PSI 11)
|
PSI
|
533
|
CHIA Hospital Discharge Database
|
X
|
|
|
Perioperative pulmonary embolism or deep vein thrombosis (PE/DVT) rate (PSI 12)
|
PSI
|
450
|
CHIA Hospital Discharge Database
|
X
|
|
|
Unrecognized abdominopelvic accidental puncture or laceration rate (PSI 15)
|
PSI
|
345
|
CHIA Hospital Discharge Database
|
X
|
|
|
Post-operative hip fracture rate (PSI 8)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Birth trauma rate: Injury to neonates (PSI 17)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Obstetric trauma: Vaginal delivery with instrument (PSI 18)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Obstetric trauma: Vaginal delivery without instrument (PSI 19)
|
PSI
|
CHIA Hospital Discharge Database
|
X
|
||
|
Acute stroke mortality rate (IQI 17)
|
IQI
|
467
|
CHIA Hospital Discharge Database
|
Added to SQMS in 2018 | |
|
Hours of physical constraint (HBIPS 2)
|
HBIPS
|
640
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
Hours of seclusion use (HBIPS 3)
|
HBIPS
|
641
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
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
|
X
|
NQF endorsement removed (formerly #558) | |
|
Post-discharge continuing care plan created (HBIPS 6)
|
HBIPS
|
CMS Hospital Compare
|
X
|
NQF endorsement removed (formerly #557) | |
|
Elective deliveries (PC-01)
|
PC
|
469
|
Leapfrog
|
X
|
|
|
Cesarean section (PC-02)
|
PC
|
471
|
Leapfrog
|
X
|
|
|
Antenatal steroids (for high risk newborn deliveries) (PC-03)
|
PC
|
476
|
Leapfrog
|
X
|
|
|
Health care-associated bloodstream infections in newborns (PC-04)
|
PC
|
1731
|
|||
|
Exclusive breast milk feeding (PC-05)
|
PC
|
480
|
|||
|
Newborn bilirubin screening
|
Leapfrog
|
X
|
|||
|
DVT prophylaxis in women undergoing cesarean section
|
473
|
Leapfrog
|
X
|
||
|
Incidence of episiotomy
|
470
|
Leapfrog
|
X
|
||
|
Aortic valve replacement
|
Leapfrog
|
X
|
|||
|
Survival predictor for pancreatic resection surgery
|
Leapfrog
|
X
|
NQF endorsement removed (formerly #738) | ||
|
Patient safety composite (PSI 90)
|
PSI
|
531
|
CHIA Hospital Discharge Database
|
X
|
|
|
Pneumonia 30-day mortality rate (risk-adjusted)
|
468
|
CMS/Hospital Compare
|
X
|
||
|
Heart failure 30-day mortality rate for patients 18 and older (risk-adjusted)
|
229
|
CMS/Hospital Compare
|
X
|
||
|
AMI 30-day mortality rate (risk-adjusted)
|
230
|
CMS/Hospital Compare
|
X
|
||
|
National Healthcare Safety Network (NHSN) hospital-onset methicillin resistant staphylococcus bacteremia aureus (MRSA)
|
1716
|
CMS/Hospital Compare
|
X
|
||
|
National Healthcare Safety Network (NHSN) central-line associated bloodstream infection
|
139
|
CMS/Hospital Compare
|
X
|
||
|
National Healthcare Safety Network (NHSN) hospital-onset C. difficile
|
1717
|
CMS/Hospital Compare
|
X
|
||
|
National Healthcare Safety Network (NHSN) catheter-associated urinary tract infections
|
138
|
CMS/Hospital Compare
|
X
|
||
|
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
|
X
|
|
|
Influenza vaccination coverage among healthcare personnel
|
CDC
|
431
|
CMS/Hospital Compare
|
Added to SQMS in 2018 | |
|
30-day all-cause risk-standardized readmission rate following AMI hospitalization
|
505
|
CMS/Hospital Compare
|
X
|
||
|
30-day all-cause risk-standardized readmission rate following heart failure (HF) hospitalization
|
330
|
CMS/Hospital Compare
|
X
|
||
|
30-day all-cause risk-standardized readmission rate following pneumonia hospitalization
|
506
|
CMS/Hospital Compare
|
X
|
||
|
30-day all-cause risk-standardized readmission rate following acute ischemic stroke hospitalization
|
CMS/Hospital Compare
|
X
|
|||
|
30-day all-cause risk-standardized readmission rate following CABG surgery
|
2515
|
CMS/Hospital Compare
|
X
|
||
|
30-Day all-cause risk-standardized readmission rate following COPD hospitalization
|
1891
|
CMS/Hospital Compare
|
X
|
||
|
30-day all-cause risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA
|
1551
|
CMS/Hospital Compare
|
X
|
|
Measure/Tool Name
|
Set
|
NQF #
|
CHIA Data Source(s)
|
Data Already Reported by CHIA
|
|
Acute care hospitalization (risk-adjusted)
|
OASIS
|
171
|
CMS/Home Health Compare
|
X
|
|
Emergency department use without hospitalization (risk-adjusted)
|
OASIS
|
173
|
CMS/Home Health Compare
|
X
|
|
Timely initiation of care
|
OASIS
|
526
|
CMS/ Home Health Compare
|
X
|
|
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
|
X
|
|
Percent of high risk residents with pressure ulcers (long stay) (risk-adjusted)
|
CMS– Minimum Data Set (MDS)
|
679
|
CMS/Nursing Home Compare
|
X
|
|
Percent of residents who self-report moderate to severe pain (short-stay)
|
CMS– Minimum Data Set (MDS)
|
676
|
CMS/Nursing Home Compare
|
X
|
|
Percent of residents who self-report moderate to severe pain (long-stay) (risk-adjusted)
|
CMS– Minimum Data Set (MDS)
|
677
|
CMS/Nursing Home Compare
|
X
|
|
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
|
CMS/ Hospice Compare
|
|
|
Hospice and palliative care – pain assessment*
|
HIS
|
1637
|
CMS/ Hospice Compare
|
|
|
Hospice and palliative care – Dyspnea screening*
|
HIS
|
1639
|
CMS/ Hospice Compare
|
|
|
Hospice and palliative care – Dyspnea treatment*
|
HIS
|
1638
|
CMS/ Hospice Compare
|
|
|
Hospice and palliative care – beliefs/values addressed*
|
HIS
|
1647
|
CMS/ Hospice Compare
|
|
|
Hospice and palliative care – treatment preferences*
|
HIS
|
1641
|
CMS/ Hospice Compare
|
*May apply to care delivered in acute and non-acute settings
**SQMS measure refers to current HEDIS specs, which are under review for NQF 18 but do not currently align
Older versions of the SQMS are available below: