Standard Quality Measure Set (SQMS) 2018


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).


Physician Group/Practice Measures

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)

 

Hospital Measures

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
 

 

Post-Acute Measures

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


Measure Set Definitions:

  • HEDIS: Healthcare Effectiveness Data and Information Set
  • IQI: Inpatient Quality Indicators
  • 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

SQMS Archive

Older versions of the SQMS are available below: