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The list below identifies measures with associated guidelines available through the Agency for Healthcare Research and Quality's (AHRQ's) NGC Web site. Measure titles are listed alphabetically by developing organization. Associated guidelines are identified below each measure title, with links to the corresponding guideline summaries on the NGC Web site.
Click on the the NQMC number to go to the corresponding NQMC measure summary.
Cardiac rehabilitation: percentage of eligible inpatients with a qualifying event/diagnosis who have been referred to an outpatient cardiac rehabilitation program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made. NQMC:3771
Cardiac rehabilitation: percentage of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the previous 12 months, who have been referred to an outpatient cardiac rehabilitation program. NQMC:3772
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for adherence to preventive medications. NQMC:3784
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for assessment of weight management. NQMC:3780
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for blood pressure control. NQMC:3777
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for diabetes mellitus or impaired fasting glucose. NQMC:3781
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for lipid control. NQMC:3778
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for physical activity habits. NQMC:3779
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for tobacco use. NQMC:3776
Obstetrics: percentage of selected primipara sustaining a perineal tear and NO episiotomy. NQMC:4818
Obstetrics: percentage of selected primipara undergoing episiotomy and NO perineal tear while giving birth vaginally. NQMC:4817
Obstetrics: percentage of selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally. NQMC:4819
Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for fourth degree tear. NQMC:4821
Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for third degree tear. NQMC:4820
Obstetrics: percentage of selected primipara with an intact perineum. NQMC:4816
Chronic obstructive pulmonary disease (COPD): the percentage of all patients with COPD diagnosed after 1st April 2008 in whom the diagnosis has been confirmed by post bronchodilator spirometry. NQMC:4149
Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD with a record of FeV1 in the previous 15 months. NQMC:4150
Coronary heart disease: the percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an angiotensin-converting enzyme (ACE) inhibitor or Angiotensin II antagonist. NQMC:4116
Coronary heart disease: the percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded). NQMC:4115
Coronary heart disease: the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less. NQMC:4113
Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months. NQMC:4112
Coronary heart disease: the percentage of patients with coronary heart disease with a record in the previous 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded). NQMC:4114
Coronary heart disease: the percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment. NQMC:4109
Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less. NQMC:4146
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of medication review involving the patient and/or carer in the previous 15 months. NQMC:4155
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months. NQMC:4154
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the previous 15 months. NQMC:4156
Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. NQMC:4187
Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the previous 15 months. NQMC:4186
Caesarean section: proportion of women delivering babies in acute care hospital by Caesarean section. NQMC:2732
Patients' experiences: percentage of veterans who die in an inpatient VA facility (intensive care, acute care, hospice unit, nursing home care unit or community living center) for whom a Bereaved Family Survey (BFS) is completed with at least 78% of items receiving an optimal response. NQMC:4939
Acute myocardial infarction/chest pain: median time from emergency department (ED) arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or chest pain patients (with probable cardiac chest pain). NQMC:4292
Acute myocardial infarction/chest pain: percentage of emergency department (ED) acute myocardial infarction (AMI) patients or chest pain patients (with probable cardiac chest pain) who received aspirin within 24 hours before ED arrival or prior to transfer. NQMC:4291
Acute myocardial infarction: median time from emergency department (ED) arrival to administration of fibrinolytic therapy in ED patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to ED arrival and prior to transfer. NQMC:4288
Acute myocardial infarction: median time to transfer to another facility for acute coronary intervention. NQMC:4290
Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. NQMC:4348
Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 100 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. NQMC:4349
Acute myocardial infarction: percentage of emergency department (ED) acute myocardial infarction (AMI) patients receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. NQMC:4289
Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. NQMC:4362
Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. NQMC:4343
Acute myocardial infarction: median time from hospital arrival to primary PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. NQMC:4345
Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. NQMC:4344
Acute myocardial infarction: percent of patients receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. NQMC:4346
Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. NQMC:4340
Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. NQMC:4339
Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. NQMC:4338
Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. NQMC:4337
Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. NQMC:4341
Heart failure: percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. NQMC:4350
Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. NQMC:4353
Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. NQMC:4351
Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. NQMC:4352
Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. NQMC:4365
Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. NQMC:4355
Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. NQMC:4361
Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. NQMC:4356
Pneumonia: percent of patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. NQMC:4357
Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. NQMC:4358
Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. NQMC:4368
Standardized developmental and behavioral screening: proportion of children whose health care provider administered a parent-completed standardized developmental and behavioral screening tool. NQMC:2972
Domestic violence: percent of adult and adolescent patients assessed who disclosed that they were victims of abuse. NQMC:1435
Domestic violence: percent of adult and adolescent patients seen by a provider who were assessed for intimate partner violence (IPV) during the last year. NQMC:1434
Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV who were offered information about IPV and referrals. NQMC:1736
Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV whose records include prompts for specific follow-up questions about IPV to occur at the patient's next visit. NQMC:1737
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted. NQMC:1734
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified assessments were conducted. NQMC:1733
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified intervention and treatment plans were offered. NQMC:1735
Domestic violence: percent of providers of health care services to adult and adolescent patients in the clinical setting who documented that they complied with assessment protocols. NQMC:1436
Acute care prevention of falls: rate of inpatient falls per 1,000 patient days. NQMC:4946
Acute care prevention of falls: rate of inpatient falls with injury per 1,000 patient days. NQMC:4947
Adult low back pain: percentage of patients with a diagnosis of back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flag." NQMC:4466
Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record. NQMC:4210
Atrial fibrillation: percentage of patients (without contraindications to anticoagulation) with paroxysmal, persistent, or permanent atrial fibrillation/flutter with risk factors for thromboembolism who are taking warfarin. NQMC:4501
Atrial fibrillation: percentage of patients with non-valvular atrial fibrillation/flutter with risk factors for thromboembolism having a CHADS2 score of 2 or greater (without contraindications to anticoagulation therapy) who are receiving warfarin. NQMC:4502
Colorectal cancer screening: percentage of African American patients age 45 and older who are up-to-date with colorectal cancer screening. NQMC:4024
Colorectal cancer screening: percentage of patients age 50 and older who are up-to-date with colorectal cancer screening. NQMC:4023
Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication. NQMC:3861
Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication. NQMC:3860
Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record. NQMC:3862
Diagnosis and management of asthma: percentage of patients with asthma with spirometry or peak flow meter reading documented in the medical record at the last visit. NQMC:3859
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients diagnosed with ADHD whose medical record contains documentation that the clinician discussed the need for school-based supports and educational service options for children with ADHD. NQMC:3266
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients newly diagnosed with ADHD whose medical record contains documentation of DSM-IV or DSM-PC criteria being addressed. NQMC:3264
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients treated with medication for the diagnosis of ADHD whose medical record contains documentation of a follow-up visit twice a year. NQMC:3265
Diagnosis and management of chronic obstructive pulmonary disease (COPD): percentage of patients with COPD whose physician inquired about smoking cessation (if patient a smoker) at every visit. NQMC:5135
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving beta-blockers within 24 hours of arrival and on discharge. NQMC:4469
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving thrombolytics with a "door-to-drug time" (time from presentation to administration of drug) of less than 30 minutes. NQMC:4468
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with chest pain symptoms in the emergency department receiving early therapy including intravenous access, oxygen, nitroglycerin, morphine and a chewable aspirin on arrival. NQMC:4467
Diagnosis and treatment of headache: percentage migraineurs with treatment plans for mild, moderate, and severe headaches. NQMC:5136
Diagnosis and treatment of headache: percentage of migraineurs who have documentation in the medical record that they have received written educational materials on migraines at a clinic/office visit. NQMC:5137
Diagnosis and treatment of otitis media in children: percentage of caregivers receiving education on the symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media. NQMC:3858
Diagnosis and treatment of otitis media in children: percentage of patients with a diagnosis of acute otitis media who were prescribed amoxicillin. NQMC:3857
Diagnosis and treatment of respiratory illness in children and adults: percentage of encounters for cold symptoms (phone care and/or office visits) for which there is documentation of home treatment education. NQMC:3855
Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis who had strep screen testing. NQMC:3856
Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than seven days and who receive an antibiotic. NQMC:3854
Diagnosis of breast disease: percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7 to 10 days. NQMC:3849
Foreign object retention: percentage of unintentionally retained foreign objects during labor and delivery. NQMC:4945
Heart failure in adults: percentage of adult heart failure patients to whom (or to their caregivers) written or verbal instructions or educational material are given during the clinic visit, addressing one or more of the following: activity level, diet, medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen (primary care and outpatient cardiology). NQMC:3536
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and met the following (for which they are eligible) at their last clinic visit: prescribed or were taking ACEI/ARB, prescribed or were on beta blocker therapy, non-smoker (primary care and outpatient cardiology). NQMC:3534
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were on beta-blocker therapy within the last 12 months of the clinic visit or who have a contraindication to taking beta-blockers (primary care and outpatient cardiology). NQMC:3533
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were taking an ACEI or ARB within the last 12 months of the clinic visit, or who have contradictions to taking both ACEI or an ARB (primary care and outpatient cardiology). NQMC:3532
Heart failure in adults: percentage of adult heart failure patients who have not used tobacco anytime during the previous year (primary care and outpatient cardiology). NQMC:3538
Heart failure in adults: percentage of adult heart failure patients who have used tobacco anytime during the previous year and who were given smoking cessation advice or counseling at the last clinic visit (primary care and outpatient cardiology). NQMC:3537
Heart failure in adults: percentage of adult heart failure patients with documentation that LVS function was evaluated or will be evaluated (primary care and outpatient cardiology). NQMC:3535
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her caregiver at discharge or during the hospital stay, addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. NQMC:3530
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge. NQMC:3526
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have a contraindication to taking beta-blockers, who are prescribed beta-blocker therapy at hospital discharge. NQMC:3528
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have contraindications to taking both ACEI and ARBs, who are prescribed an ACEI or an ARB at hospital discharge. NQMC:3527
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have used tobacco anytime during the year prior to hospital arrival and who are given smoking cessation advice or counseling during the hospital stay or at discharge. NQMC:3531
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. NQMC:3529
Hypertension diagnosis and treatment: percentage of adult patients who have blood pressure less than 140/90 mmHg at their clinic visit. NQMC:4470
Hypertension diagnosis and treatment: percentage of adult patients with hypertension, presenting in clinic within the last month, for whom patient education about modifiable risk factors has been documented in the medical record. NQMC:4471
Immunizations: percentage of adolescents who are on time with recommended immunizations (Hep B, Hep A, HPV, MMR, MCV4, Tdap, VZV). NQMC:4453
Immunizations: percentage of two-year-old patients who are on time with their primary series of immunizations (DTaP, IPV, MMR/MMRV, PCV7/PPV23, VZV, Hib, Hep B, Hep A, Rota, Influenza). NQMC:4452
Initial management of abnormal cervical cytology (Pap smear) and human papillomavirus (HPV) testing: percentage of adult women diagnosed with initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk HPV type who have follow-up colposcopy within six months of abnormality identified. NQMC:4454
Lipid management in adults: percentage of patients on a lipid lowering medication who have a fasting lipid panel every 3 to 12 months. NQMC:3395
Lipid management in adults: percentage of patients with diagnosed coronary heart disease (CHD) or CHD equivalent who have had a diet evaluation. NQMC:3394
Major depression in adults in primary care: percentage of patients who commit suicide at any time while under depression management with a primary care physician. NQMC:4015
Major depression in adults in primary care: percentage of patients who have a depression follow-up contact within three months of initiating treatment. NQMC:4010
Major depression in adults in primary care: percentage of patients who have had a response to treatment at six months (+/- 30 days) after initiating treatment i.e., have had a Patient Health Questionnaire (PHQ-9) score decreased by 50% from initial score at six months (+/- 30 days). NQMC:4012
Major depression in adults in primary care: percentage of patients who have reached remission at six months (+/- 30 days) after initiating treatment, i.e., have any PHQ-9 score less than five after six months (+/- 30 days). NQMC:4013
Major depression in adults in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as Patient Health Questionnaire [PHQ-9]) within three months of initiating treatment. NQMC:4011
Major depression in adults in primary care: percentage of patients with a new diagnosis of major depression, with documentation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria within the three months prior to initial diagnosis. NQMC:4009
Major depression in adults in primary care: percentage of patients with diabetes with documentation of screening for depression. NQMC:4014
Management of labor: percentage of births with amnioinfusion when either of the following is present: thick meconium or repetitive severe variable decelerations or oligohydramnios. NQMC:3149
Management of labor: percentage of women in the guideline population who have spontaneous rupture of membranes (SROM) or early amniotomy. NQMC:3146
Management of labor: percentage of women in the guideline population with failure to progress diagnosis who have oxytocin. NQMC:3147
Management of labor: percentage of women who are assessed for risk status on entry to labor and delivery. NQMC:3148
Menopause and hormone therapy (HT): collaborative decision-making and management: percentage of women in menopause who have had a bone mineral density (BMD) measurement a year after cessation of HT. NQMC:4455
Palliative care: percentage of adult patients with a progressive, debilitating disease who have a palliative care plan documented in the medical record. NQMC:4008
Preoperative evaluation: percentage of patients with a preoperative health history and physical examination completed prior to the day of scheduled procedure. NQMC:4209
Preventive services for adults: percentage of patients with all Level I preventive services on time according to the guideline delivery schedule. NQMC:4456
Preventive services for children and adolescents: the percentage of patients who are on time with recommended immunizations. NQMC:4457
Routine prenatal care: percentage of all identified preterm birth (PTB) modifiable risk factors assessed that receive an intervention. NQMC:4212
Routine prenatal care: percentage of pregnant women who report to have received counseling and education by the 28th week visit. NQMC:4211
Routine prenatal care: percentage of vaginal birth after cesarean (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). NQMC:4213
Safe site invasive procedure -- non-operating room: percentage of appropriate invasive procedure patients who had their site marked by the provider performing the invasive radiological procedure. NQMC:4949
Safe site invasive procedure -- non-operating room: percentage of cases in which a verbal, active Time Out is conducted by providers present with the patient prior to the start of the procedure. NQMC:4951
Safe site invasive procedure -- non-operating room: percentage of invasive procedure patients with documentation of verification of correct patient, site/side and procedure. NQMC:4950
Safe site invasive procedure -- non-operating room: percentage of wrong invasive or high-risk radiological procedure events outside of the operating room per month. NQMC:4948
Skin safety protocol -- risk assessment and prevention of pressure ulcers: percentage of patients with documentation in the medical record that a head-to-toe skin inspection and palpation were completed within six hours of admission. NQMC:4943
Stable coronary artery disease (CAD): percentage of patients with stable CAD who have aspirin use documented in the medical record. NQMC:3183
Venous thromboembolism (VTE) diagnosis and treatment: percentage of adult patients suspected of deep vein thrombosis (DVT) who have leg duplex ultrasound with compression performed despite a low clinical pretest probability and a negative D-dimer test. NQMC:5141
Venous thromboembolism (VTE) diagnosis and treatment: percentage of adult patients treated for VTE who have been assessed for the need for graded compression stockings (not Teds). NQMC:5138
Venous thromboembolism (VTE) diagnosis and treatment: percentage of adult patients who have a high clinical pretest probability for pulmonary embolism (PE) who received low molecular weight heparin (LMWH) during evaluation. NQMC:5139
Venous thromboembolism (VTE) diagnosis and treatment: percentage of low-molecular-weight heparin (LMWH)-eligible patients with deep vein thrombosis (DVT) treated in an outpatient setting. NQMC:5143
Venous thromboembolism (VTE) diagnosis and treatment: percentage of patients diagnosed with VTE who meet the criteria for low-molecular-weight heparin (LMWH) and for whom LMWH is used. NQMC:5142
Venous thromboembolism (VTE) diagnosis and treatment: percentage of patients with VTE receiving heparin therapy who have a baseline platelet count before starting heparin, and then a platelet count every other day for at least the first 3 days of therapy. NQMC:5140
Venous thromboembolism prophylaxis: percentage of adult hospitalized patients who are assessed for venous thromboembolism risk within 24 hours of admission. NQMC:4472
Venous thromboembolism prophylaxis: percentage of hospitalized adult patients who require hospital readmission within 30 days of discharge for conditions related to venous thromboembolism. NQMC:4473
Acute myocardial infarction: percent of patients who expired during hospital stay. NQMC:4347
Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification. NQMC:4529
Hospital-based inpatient psychiatric services: the percentage of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications. NQMC:4528
Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. NQMC:4359
Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. NQMC:4363
Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. NQMC:4364
Acute stroke care: percentage of eligible carers of stroke patients who undertook documented training prior to discharge of hospital during audit period. NQMC:4336
Acute stroke care: percentage of eligible stroke patients diagnosed with a ischaemic stroke with documented evidence of recombinant tissue-type plasminogen activator (rt-PA) administered during audit period. NQMC:4327
Acute stroke care: percentage of ischaemic stroke patients with documented evidence that antithrombotic agent was prescribed and administered prior to discharge from the hospital during audit period. NQMC:4332
Acute stroke care: percentage of stroke patients admitted to stroke unit during acute hospital stay during audit period. NQMC:4323
Acute stroke care: percentage of stroke patients diagnosed with an ischemic stroke with documented evidence of aspirin administration administered within 48 hours of presentation to hospital during audit period. NQMC:4326
Acute stroke care: percentage of stroke patients discharged from acute care with documented assessment of mood during audit period. NQMC:4331
Acute stroke care: percentage of stroke patients with documented care plan developed and provided to patient/family prior to hospital discharge during audit period. NQMC:4334
Acute stroke care: percentage of stroke patients with documented education provided during hospital stay during audit period. NQMC:4335
Acute stroke care: percentage of stroke patients with documented evidence of CT conducted within 24 hours of presentation to hospital during audit period. NQMC:4325
Acute stroke care: percentage of stroke patients with documented evidence of swallow screen conducted prior to documented evidence of food or fluid intake during audit period. NQMC:4324
Acute stroke care: percentage of stroke patients with documented evidence that antihypertensive agent was prescribed and administered prior to discharge from the hospital during audit period. NQMC:4333
Acute stroke care: percentage of stroke patients with documented occupational therapist assessment within 48 hours of admission to the hospital during audit period. NQMC:4329
Acute stroke care: percentage of stroke patients with documented physiotherapy assessment within 48 hours of admission to hospital during audit period. NQMC:4328
Acute stroke care: percentage of stroke patients with documented speech pathologist assessment within 48 hours of admission to hospital during audit period. NQMC:4330
Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain. NQMC:3151
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy. NQMC:3152
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations. NQMC:3150
Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees). NQMC:3480
Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made. NQMC:4005
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period. NQMC:4004
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented. NQMC:4003
Child and adolescent major depressive disorder: percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with a plan for follow-up care documented. NQMC:4441
Child and adolescent major depressive disorder: percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk. NQMC:4438
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder for whom an antidepressant medication was considered or prescribed during an episode of major depressive disorder. NQMC:4440
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who received or were referred for psychotherapy during an episode of major depressive disorder. NQMC:4439
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who were interviewed directly by the evaluating clinician on or before the date of diagnosis. NQMC:4436
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified. NQMC:4437
Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care. NQMC:3790
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period. NQMC:3788
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile. NQMC:3789
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period. NQMC:3792
Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care. NQMC:3787
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings. NQMC:4411
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique. NQMC:4410
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of chronic skin ulcer undergoing debridement with documentation of wound characteristics (including at a minimum: size, AND nature of wound base tissue, AND amount of drainage) prior to debridement. NQMC:4412
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who received education regarding appropriate foot care AND daily inspection of the feet within the 12 month reporting period. NQMC:4416
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who were prescribed an appropriate method of offloading (pressure relief) within the 12 month reporting period. NQMC:4415
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who received education regarding the need for long term compression therapy including interval replacement of compression stockings within the 12 month reporting period. NQMC:4414
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were prescribed compression therapy within the 12 month reporting period. NQMC:4413
Emergency medicine: percentage of patients (regardless of age) with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG. NQMC:2951
Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed. NQMC:2945
End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V greater than or equal to 1.2 OR patients have a Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis. NQMC:3808
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula OR patients who are referred for an AV fistula at least once during the 12 month reporting period. NQMC:3805
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times (every 4 months) during the 12 month reporting period. NQMC:3809
Endoscopy and polyp surveillance: percentage of final colonoscopy reports for patients aged 18 years and older that include documentation of all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowel prep; complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; and recommendations for follow-up. NQMC:4499
Endoscopy and polyp surveillance: percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report. NQMC:4498
Endoscopy and polyp surveillance: percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report. NQMC:4497
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence. NQMC:3799
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months. NQMC:2929
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months. NQMC:3798
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence. NQMC:3800
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery. NQMC:3801
Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery. NQMC:3802
Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months. NQMC:2924
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented. NQMC:2928
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months. NQMC:2925
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months. NQMC:2926
Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months. NQMC:2927
Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months. NQMC:4021
Hepatitis C: percentage of female patients aged 18 to 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of antiviral treatment. NQMC:3170
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment. NQMC:3164
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks from initiation of antiviral treatment. NQMC:3166
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment. NQMC:3163
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed peginterferon and ribavirin therapy within the 12 month reporting period. NQMC:3165
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C with genotype 1 or 4 who are receiving antiviral treatment at week 24 for whom quantitative HCV RNA testing was performed at 24 weeks of treatment. NQMC:3171
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed. NQMC:3162
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A. NQMC:3167
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B. NQMC:3168
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period. NQMC:3169
Nuclear medicine - radionuclide bone imaging: percentage of patients, regardless of age, undergoing bone scintigraphy, considered to be potentially at risk for fracture in a weight-bearing site for whom there is documentation of direct communication to the referring physician within 24 hours of completion of the imaging study. NQMC:4002
Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy. NQMC:3770
Pediatric end stage renal disease (ESRD): percentage of calendar months during the 12 month reporting period in which patients aged 17 years and younger with a diagnosis of ESRD receiving hemodialysis have a single-pool Kt/V greater than or equal to 1.2 or have a single-pool Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis. NQMC:4417
Perioperative care: percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time. NQMC:2917
Preventive care and screening: percentage of female patients who had a mammogram performed during the two-year measurement period. NQMC:1958
Preventive care and screening: percentage of patients 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user. NQMC:4462
Preventive care and screening: percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user. NQMC:4458
Preventive care and screening: percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method. NQMC:4463
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2. NQMC:2905
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin. NQMC:2942
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period. NQMC:4007
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period. NQMC:4006
Acute coronary syndrome (ACS): percent of patients hospitalized for ACS with cardiac symptoms prior to or on arrival to the acute setting who had an ECG performed 15 minutes prior to arrival in acute setting or within 10 minutes after arrival. NQMC:2484
Alcohol misuse: percent of patients screened for alcohol misuse with AUDIT-C who meet or exceed a threshold score of 5 who have timely brief alcohol counseling. NQMC:3830
Cardiovascular: percent of patients discharged with AMI, CABG, PTCA (inpatient or outpatient), or with ischemic vascular disease who have had a full lipid panel in the past year. NQMC:3817
Hypertension: percent of eligible patients with an active diagnosis of hypertension whose most recent blood pressure recording was less than 140/90 mm Hg. NQMC:2493
Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive mono-drug therapy where the regimen includes a thiazide diuretic. NQMC:2876
Hypertension: percent of outpatients with a diagnosis of hypertension (uncomplicated) on antihypertensive multi-drug therapy where the regimen includes a thiazide diuretic. NQMC:2877
Infection rate reduction: number of ventilator-associated pneumonia (VAP) infections per 1,000 ventilator days. NQMC:3827
Ischemic heart disease (IHD): percent of patients discharged with AMI, CABG, PTCA (inpatient or outpatient), or with ischemic vascular disease who have had a full lipid panel in the past year and LDL-C less than 100 on most recent test in past year. NQMC:2495
Mental Health Intensive Case Management (MHICM): percent of psychosis patients projected as requiring MHICM who receive outpatient care in MHICM. NQMC:2472
Mental health: percent of eligible patients screened at required intervals for PTSD. NQMC:2878
Smoking cessation: percent of patients using tobacco who have been offered a referral to smoking cessation specialty program to assist with cessation within the past year. NQMC:3818
Smoking cessation: percent of patients using tobacco who have been offered medications to assist with cessation. NQMC:2882
Smoking cessation: percent of patients using tobacco who have been provided with brief counseling within the past year. NQMC:2885
Parkinson's disease (PD): percentage of veterans with idiopathic Parkinson's disease who have developed end-of-dose wearing-off and have impairments in activities of daily living who are offered within three months 1) addition of a dopamine agonist, 2) addition of a catechol o-methyltransferase (COMT) inhibitor, 3) more frequent dosing of levodopa, OR 4) addition of a selective MAO-B inhibitor or amantadine. NQMC:4442
Parkinson's disease (PD): percentage of veterans with idiopathic PD being treated for depression with antidepressants for whom the antidepressants are prescribed at appropriate starting doses and have an appropriate titration schedule to a therapeutic dose, therapeutic blood level or remission of symptoms by 12 weeks. NQMC:4447
Parkinson's disease (PD): percentage of veterans with idiopathic PD diagnosed with depression who are offered antidepressant treatment, psychotherapy, or electroconvulsive therapy (ECT) within 2 weeks after diagnosis. NQMC:4446
Parkinson's disease (PD): percentage of veterans with idiopathic PD given a dopamine agonist as monotherapy who are started at a low dose and gradually titrated to the therapeutic range. NQMC:4443
Parkinson's disease (PD): percentage of veterans with idiopathic PD having persistent medication-induced hallucinations or delirium not improved by PD medication adjustments for whom high-potency neuroleptics, olanzapine and risperidone are not used to manage symptoms. NQMC:4445
Parkinson's disease (PD): percentage of veterans with idiopathic PD prescribed a new drug who have documentation of the response to therapy and occurrence of drug side-effects within 6 months. NQMC:4444
Parkinson's disease (PD): percentage of veterans with idiopathic PD who have documentation that they were asked at least annually about the occurrence of depression. NQMC:4450
Parkinson's disease (PD): percentage of veterans with idiopathic PD who have documentation that they were asked at least annually about the occurrence of hallucinations. NQMC:4451
Parkinson's disease (PD): percentage of veterans with idiopathic PD who have documentation that they were asked at least annually about the occurrence of recent falls. NQMC:4449
Parkinson's disease (PD): percentage of veterans with idiopathic PD who have documentation that they were asked at least annually about the occurrence of recent orthostatic hypotension. NQMC:4448
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Date Modified: 11/16/2009
