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ADMINISTRATIVE BULLETIN 16-10957 CMR 4.00: Uniform Provider Reporting of the Standard Quality Measure SetEffective November 18, 2016The Center for Health Information and Analysis (Center) is issuing this Administrative Bulletin in accordance with 957 CMR 4.05(1) to notify Providers, as defined in 957 CMR 4.02, of the updates to the quality measures in the Standard Quality Measure Set (SQMS). The changes to the SQMS outlined below were recommended to the Center by the Statewide Quality Advisory Committee (SQAC) on October 31, 2016. Pursuant to M.G.L. c. 12C, § 14, the SQAC is required to make its recommendation of SQMS measures to the Center annually, on or before November 1. The SQAC’s 2016 recommendation added six measures to and removed twenty-one measures from the SQMS. The six measures that were added are:Follow-up after emergency department visit for mental illness (HEDIS)Follow-up after emergency department visit for alcohol or other drug dependence (HEDIS)Depression remission or response for adolescents and adults (HEDIS)Statin therapy for patients with cardiovascular conditions (HEDIS)Statin therapy for patients with diabetes (HEDIS)Patients discharged on multiple antipsychotic medications with appropriate justification (HBIPS 5)The twenty-one measures that were removed are:Use of appropriate medications for people with asthma (HEDIS)Human Papillomavirus vaccine for female adolescents (HEDIS)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)Annual dental visit (HEDIS)Aspirin use and discussion (HEDIS)CAHPS Health Plan Survey v 3.0 children with chronic conditions supplement (HEDIS)Counseling on physical activity in older adults (HEDIS)Fall risk management (HEDIS)Flu shots for adults ages 18-64 (HEDIS)Flu shots for adults ages 65 and older (HEDIS)Medical assistance with smoking and tobacco use cessation (HEDIS)Osteoporosis testing in older women (HEDIS)Pneumococcal vaccination status for older adults (HEDIS)Urinary incontinence management in older adults (HEDIS)The SQMS now includes the following measures: Physician Group/Practice MeasuresCountMeasure/Tool NameSetNQF #1Consumer assessment of healthcare providers and systems (CAHPS) - clinician & group surveyCAHPS52Therapeutic monitoring: Annual monitoring for patients on persistent medicationsHEDIS23713Use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD)HEDIS5774Controlling high blood pressureHEDIS185Comprehensive?diabetes careHEDIS6Disease modifying anti-rheumatic drug therapy for rheumatoid arthritisHEDIS547Osteoporosis management in women who had a fractureHEDIS538Pharmacotherapy of chronic obstructive pulmonary disease (COPD) exacerbationHEDIS28569Medication management for people with asthmaHEDIS179910Asthma medication ratioHEDIS180011Potentially harmful drug-disease interactions in the elderlyHEDIS12Avoidance of antibiotic treatment in adults with acute bronchitisHEDIS5813Use of imaging studies for low back painHEDIS5214Use of high-risk medications in the elderlyHEDIS2215Care for older adults - medication reviewHEDIS55316Persistence of beta-blocker treatment after a heart attackHEDIS7117Medication reconciliation post-dischargeHEDIS55418Appropriate treatment for children with upper respiratory infectionHEDIS6919Well-child visits in the third, fourth, fifth and sixth years of lifeHEDIS151620Appropriate testing of children with pharyngitisHEDIS21Follow-up care for children prescribed ADHD medicationHEDIS10822Adolescent well-care visitsHEDIS23Childhood immunization statusHEDIS3824Immunizations for adolescentsHEDIS140725Lead screening in childrenHEDIS26Weight assessment and counseling for nutrition and physical activity for children/adolescentsHEDIS2427Children and adolescents' access to primary care practitionersHEDIS28Frequency of ongoing prenatal careHEDIS139129Prenatal and postpartum careHEDIS151730Well-child visits in the first 15 months of lifeHEDIS139231Breast cancer screeningHEDIS237232Colorectal cancer screeningHEDIS3433Cervical cancer screeningHEDIS3234Chlamydia screening in womenHEDIS3335Adult BMI assessmentHEDIS36Adults' access to preventive/ambulatory health servicesHEDIS37Initiation and engagement of alcohol and other drug dependence treatmentHEDIS438Antidepressant medication managementHEDIS10539Follow-up after hospitalization for mental illnessHEDIS57640Adherence to antipsychotics for individuals with schizophreniaHEDIS187941Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medicationsHEDIS193242Diabetes monitoring for people with diabetes and schizophreniaHEDIS193443Cardiovascular monitoring for people with cardiovascular disease and schizophreniaHEDIS193344Non-recommended cervical cancer screening in adolescent femalesHEDIS45Non-recommended PSA-based screening in older menHEDIS46Use of multiple concurrent antipsychotics in children and adolescentsHEDIS47Metabolic monitoring for children and adolescents on antipsychoticsHEDIS280048Use of first-line psychosocial care for children and adolescents on antipsychoticsHEDIS280149Follow-up after emergency department visit for mental illness ?HEDIS260550Follow-up after emergency department visit for alcohol or other drug dependence ?HEDIS260551Depression remission or response for adolescents and adults ?HEDIS52Statin therapy for patients with cardiovascular conditions ?HEDIS53Statin therapy for patients with diabetes ?HEDIS54Asthma in younger adults admission rate (PQI 15)PQI28355Chronic obstructive pulmonary disease (COPD) or asthma in older adults admission rate (PQI 5)PQI27556Heart failure admission rate (PQI 8)PQI27757Diabetes short-term complications admission rate (PQI 1)PQI27258Low birth weight rate (PQI 9)PQI27859Screening for clinical depression and follow-up plan41860Preventive care & screening: Tobacco use: Screening and cessation interventionAMA-PCPI2861Preventive care & screening: Unhealthy alcohol use: screening & brief counselingAMA-PCPI215262Asthma emergency department Visits63Depression utilization of the PHQ-9 toolMN Community Management71264Maternal depression screening65Depression screening by 18 years of ageHospital MeasuresCountMeasure/Tool NameSetNQF #66VTE prophylaxis (STK-1)STK43467Thrombolytic therapy (STK-4)STK43768Discharged on statin (STK-6)STK43969Stroke education (STK-8)STK70VTE prophylaxis (VTE-1)VTE37171ICU VTE prophylaxis (VTE-2)VTE37272VTE patients w/anticoagulation (VTE-3 )VTE37373VTE Warfarin therapy discharge instructions (VTE-5 )VTE74Hospital acquired potentially-preventable VTE (VTE-6)VTE75Severe sepsis & septic shock: Management bundle (SEP-1)SEP50076Influenza immunization (IMM 2)IMM165977Relievers for inpatient asthma (CAC 1)CAC78Systemic corticosteroids for inpatient asthma (CAC 2)CAC79Hospital-wide all-cause unplanned readmission measure (HWR)Yale/CMS178980Timely transmission of transition record (CCM 3)AMA-PCPI64881Fibrinolytic therapy received within 30 minutes of hospital arrival (AMI 7a)AMI82Hospital consumer assessment of healthcare providers and systems (HCAHPS) CAHPS166/22883Computerized physician order entry standards84Pressure ulcer rate (PSI 3)PSI85Iatrogenic pneumothorax rate (PSI 6)PSI34686Central venous catheter-related blood stream infection rate (PSI 7)PSI87Post-operative respiratory failure rate (PSI 11)PSI53388Perioperative pulmonary embolism or deep vein thrombosis (PE/DVT) Rate (PSI 12)PSI45089Unrecognized abdominopelvic accidental puncture or laceration rate (PSI 15)PSI34590Post-operative hip fracture rate (PSI 8)PSI91Birth trauma rate: Injury to neonates (PSI 17)PSI92Obstetric trauma: Vaginal delivery with instrument (PSI 18)PSI93Obstetric trauma: Vaginal delivery without instrument (PSI 19)PSI94Patients discharged on multiple antipsychotic medications with appropriate justification (HBIPS 5) ?HBIPS56095Post-discharge continuing care plan transmitted to next level of care provider upon discharge (HBIPS 7)HBIPS96Post-discharge continuing care plan created (HBIPS 6)HBIPS97Elective deliveries (PC-01)PC46998Cesarean section (PC-02)PC47199Antenatal steroids (for high risk newborn deliveries) (PC-03)PC476100Health care-associated bloodstream infections in newborns (PC-04)PC1731101Exclusive breast milk feeding (PC-05)PC480102Newborn bilirubin screening103DVT prophylaxis in women undergoing cesarean section473104Incidence of episiotomy470105Aortic valve replacement106Survival predictor for pancreatic resection surgery107Patient safety composite (PSI 90)PSI531108Pneumonia 30-day mortality rate (risk-adjusted)468109Heart failure 30-day mortality rate for patients 18 and older (risk-adjusted)229110AMI 30-day mortality rate (risk-adjusted)230111National Healthcare Safety Network (NHSN) hospital-onset methicillin resistant staphylococcus bacteremia aureus (MRSA)1716112National Healthcare Safety Network (NHSN) central-line associated bloodstream infection139113National Healthcare Safety Network (NHSN) hospital-onset C. difficile1717114National Healthcare Safety Network (NHSN) catheter-associated urinary tract infections138115American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) harmonized procedure specific surgical site (SSI) outcome measureCDC75311630-day all-cause risk-standardized readmission rate following AMI hospitalization50511730-day all-cause risk-standardized readmission rate following heart failure (HF) hospitalization33011830-day all-cause risk-standardized readmission rate following pneumonia hospitalization50611930-day all-cause risk-standardized readmission rate following acute ischemic stroke hospitalization12030-day all-cause risk-standardized readmission rate following CABG surgery251512130-Day all-cause risk-standardized readmission rate following COPD hospitalization189112230-day all-cause risk-standardized readmission rate following elective primary THA and/or TKA1551Post-Acute MeasuresCountMeasure/Tool NameSetNQF #123Acute care hospitalization (risk-adjusted)OASIS171124Emergency department use without hospitalization (risk-adjusted)OASIS173125Timely initiation of careOASIS526126Percent of residents with pressure ulcers that are new or worsened (short-stay) (risk-adjusted)CMS– Minimum Data Set (MDS)678127Percent of high risk residents with pressure ulcers (long stay) (risk-adjusted)CMS– Minimum Data Set (MDS)679128Percent of residents who self-report moderate to severe pain (short-stay)CMS– Minimum Data Set (MDS)676129Percent of residents who self-report moderate to severe pain (long-stay) (risk-adjusted)CMS– Minimum Data Set (MDS)677130Proportion admitted to hospice for less than 3 days216131Advance care planAMA-PCPI/NCQA326132Palliative and end of life care: Dyspnea screening & management133Hospice and palliative care – pain screening*HIS1634134Hospice and palliative care – pain assessment*HIS1637135Hospice and palliative care – dyspnea screening*HIS1639136Hospice and palliative care – dyspnea treatment*HIS1638137Hospice and palliative care – beliefs/values addressed*HIS1647138Hospice and palliative care – treatment preferences*HIS1641Key* May apply to care delivered in acute and non-acute settings? Measure added in 2016 ................
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