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Measure Summaries In Progress

NQMC is currently working on 37 measures that have met the NQMC Inclusion Criteria. Measure titles, and their respective Measure Collections, are listed alphabetically by measure developer.

New reflects measures added to the NQMC work queue within the last 2 weeks.

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A

AAAHC Institute for Quality Improvement, Performance Measurement Initiative, Colonoscopy Work Group (1)

AAAHC Institute for Quality Improvement Performance Measurement Initiative

New Intra-procedure colonoscopy complication rate: percentage of patients who developed one or more intra-procedure colonoscopy complications.

American College of Chest Physicians (7)

Quality Indicators for the Evaluation of Patients with Lung Cancer

Lung cancer: percentage of active smokers with lung cancer who have had smoking cessation counseling documented.

Lung cancer: percentage of non-surgical biopsies in patients with clinical stage IV non-squamous non-small cell lung cancer that obtained an adequate amount of tissue for molecular testing.

Lung cancer: percentage of patients with clinical stage IB or higher, but no evidence of metastatic disease, who have had a mediastinal lymph node sampling procedure performed prior to the initiation of curative intent therapy.

Lung cancer: percentage of patients with clinical stage III or IV lung cancer, or neurologic symptoms, who have had brain imaging performed within 3 months prior to the initiation of treatment.

Lung cancer: percentage of patients with evidence of one to three distant metastases who have had an attempt at biopsy confirmation of a site of metastasis, or documentation of a reason that this was not possible or necessary.

Lung cancer: percentage of patients with lung cancer in whom a performance status measure is documented prior to treatment.

Lung cancer: percentage of patients with lung cancer who have an American Joint Committee on Cancer (AJCC) eighth edition clinical lung cancer stage documented prior to curative intent therapy.

American Gastroenterological Association (1)

Colorectal Cancer Screening

New Colorectal cancer screening: percentage of patients aged 50 to 75 years 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.

C

Centers for Medicare & Medicaid Services (3)

Hospital Outpatient Department Quality Measures

New Imaging efficiency: percentage of patients with mammography screening studies that are followed by a diagnostic mammography, ultrasound or MRI of the breast in an outpatient or office setting within 45 days.

New Outpatient colonoscopy: facility level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy.

National Hospital Inpatient Quality Measures

Sepsis: percentage of inpatients age 18 and over with a diagnosis of severe sepsis or septic shock who had the following performed, consistent with the Surviving Sepsis Campaign guidelines: measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.

D

Division of General Thoracic Surgery, Mayo Clinic (13)

Patient-Centered Quality Indicators for Pulmonary Resection

Pulmonary resection: in-hospital and 30-day operative mortality rate.

Pulmonary resection: percentage of patients over the age of 50 years undergoing pulmonary resection for whom an electrocardiogram (ECG) was obtained within 90 days before lung resection.

Pulmonary resection: percentage of patients undergoing pulmonary resection for whom forced expiratory volume in one second (FEV1) and diffusing capacity of carbon monoxide (DLCO) was obtained within 365 days before lung resection.

Pulmonary resection: percentage of patients undergoing pulmonary resection who are smoking at the time of or have quit within 30 days of pulmonary resection who have documentation that smoking cessation consultation was offered.

Pulmonary resection: percentage of patients undergoing pulmonary resection who had treatment implemented with documented reassessment of pain score within 2 hours.

Pulmonary resection: percentage of patients undergoing pulmonary resection who have a documented follow-up plan at time of patient discharge from hospital.

Pulmonary resection: percentage of patients undergoing pulmonary resection who have documentation of analog pain scores greater than or equal to 6 out of 10 during hospitalization.

Pulmonary resection: percentage of patients undergoing pulmonary resection who have documentation of any of the National Quality Forum (NQF) "never events" relevant to general thoracic surgery.

Pulmonary resection: percentage of patients undergoing pulmonary resection who have documentation of at least one of the specified deep venous thrombosis prophylaxis modalities after surgery.

Pulmonary resection: percentage of patients undergoing pulmonary resection who have documentation of the use of postoperative incentive spirometry.

Pulmonary resection: percentage of patients undergoing pulmonary resection who received treatment within 45 minutes of onset of rapid ventricular response.

Pulmonary resection: percentage of patients undergoing pulmonary resection whose smoking history was documented preoperatively.

Pulmonary resection: percentage of patients with lung cancer undergoing pulmonary resection who have documentation of at least one of the specified mediastinal staging procedures.

S

Sandsdalen, Tuva, MNS, CCRN, RNT; Wilde-Larsson, Bodil, PhD, RNT (7)

Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC)

Palliative care: mean score on the "Best possible help to take care of personal hygiene" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Best possible medical care" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Identity-Oriented Approach" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Medical-Technical Competence" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Physical-Technical Conditions" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Pleasant and secure atmosphere on the ward" item on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

Palliative care: mean score on the "Socio-Cultural Atmosphere" dimension on the Quality from the Patient's Perspective Instrument Specific to Palliative Care (QPP-PC).

U

University of North Carolina at Chapel Hill (5)

Palliative Care and End-of-Life Care

Palliative and end-of-life care: percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.

Palliative and end-of-life care: percentage of hospice or palliative care patients who were screened for dyspnea during the hospice admission evaluation/palliative care initial encounter.

Palliative and end-of-life care: percentage of hospice or palliative care patients who were screened for pain during the hospice admission evaluation/palliative care initial encounter.

Palliative and end-of-life care: percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.

Palliative and end-of-life care: percentage of patients with chart documentation of preferences for life sustaining treatments.

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