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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: