Quality measures
Buy a license2025 quality measures
Collection types
| Quality ID | Measure Name | CQMS PDF | Collection Type |
|---|---|---|---|
| 1 | Diabetes: Glycemic Status Assessment Greater Than 9% |  | |
| 5 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) |  | |
| 6 | Coronary Artery Disease (CAD): Antiplatelet Therapy |  | |
| 7 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) |  | |
| 8 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) |  | |
| 9 | Anti-depressant Medication Management | ||
| 12 | Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | ||
| 19 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | ||
| 24 | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older |  | |
| 39 | Screening for Osteoporosis for Women Aged 65-85 Years of Age |  | |
| 47 | Advance Care Plan |  | |
| 48 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older |  | |
| 50 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older |  | |
| 52 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy |  | |
| 65 | Appropriate Treatment for Upper Respiratory Infection (URI) |  | |
| 66 | Appropriate Testing for Pharyngitis |  | |
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients |  | |
| 112 | Breast Cancer Screening |  | |
| 113 | Colorectal Cancer Screening |  | |
| 116 | Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis |  | |
| 117 | Diabetes: Eye Exam |  | |
| 118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) |  | |
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy — Neurological Evaluation |  | |
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear |  | |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |  | |
| 130 | Documentation of Current Medications in the Medical Record |  | |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan |  | |
| 141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care |  | |
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified |  | |
| 144 | Oncology: Medical and Radiation – Plan of Care for Pain |  | |
| 145 | Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy |  | |
| 155 | Falls: Plan of Care |  | |
| 164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation |  | |
| 167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure |  | |
| 168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration |  | |
| 176 | Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy |  | |
| 177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity |  |
|
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment |  | |
| 180 | Rheumatoid Arthritis (RA): Glucocorticoid Management |  | |
| 181 | Elder Maltreatment Screen and Follow-Up Plan |  | |
| 182 | Functional Outcome Assessment |  | |
| 185 | Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use |  | |
| 187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy |  | |
| 191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery |  | |
| 205 | Sexually Transmitted Infection (STI) Testing for People with HIV |  | |
| 217 | Functional Status Change for Patients with Knee Impairments |  | |
| 218 | Functional Status Change for Patients with Hip Impairments |  | |
| 219 | Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments |  | |
| 220 | Functional Status Change for Patients with Low Back Impairments |  | |
| 221 | Functional Status Change for Patients with Shoulder Impairments |  | |
| 222 | Functional Status Change for Patients with Elbow, Wrist or Hand Impairments |  | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |  | |
| 236 | Controlling High Blood Pressure |  | |
| 238 | Use of High-Risk Medications in Older Adults |  | |
| 239 | Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | ||
| 240 | Childhood Immunization Status | ||
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting |  | |
| 249 | Barrett’s Esophagus |  | |
| 250 | Radical Prostatectomy Pathology Reporting |  | |
| 259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) |  | |
| 261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness |  | |
| 264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer |  | |
| 268 | Counseling for Women of Childbearing Potential with Epilepsy |  | |
| 275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy |  | |
| 277 | Sleep Apnea: Severity Assessment at Initial Diagnosis |  | |
| 279 | Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy |  | |
| 281 | Dementia: Cognitive Assessment | ||
| 282 | Dementia: Functional Status Assessment |  | |
| 286 | Safety Concern Screening and Follow-Up for Patients with Dementia |  | |
| 288 | Dementia: Education and Support of Caregivers for Patients with Dementia |  | |
| 290 | Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease |  | |
| 291 | Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease |  | |
| 293 | Rehabilitative Therapy Referral for Patients with Parkinson’s Disease |  | |
| 303 | Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery |  | |
| 304 | Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery |  | |
| 305 | Initiation and Engagement of Substance Use Disorder Treatment | ||
| 309 | Cervical Cancer Screening | ||
| 310 | Chlamydia Screening in Women | ||
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented |  | |
| 318 | Falls: Screening for Future Fall Risk | ||
| 320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients |  | |
| 322 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients |  | |
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy |  | |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) |  | |
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) |  | |
| 335 | Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) |  | |
| 336 | Maternity Care: Postpartum Follow-up and Care Coordination |  | |
| 338 | HIV Viral Suppression |  | |
| 340 | HIV Annual Retention in Care |  | |
| 344 | Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) |  | |
| 350 | Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy |  | |
| 351 | Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation |  | |
| 354 | Anastomotic Leak Intervention |  | |
| 355 | Unplanned Reoperation within the 30-Day Postoperative Period |  | |
| 356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure |  | |
| 357 | Surgical Site Infection (SSI) |  | |
| 358 | Patient-Centered Surgical Risk Assessment and Communication |  | |
| 360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies |  | |
| 364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines |  | |
| 366 | Follow-Up Care for Children Prescribed ADHD Medication (ADD) | ||
| 370 | Depression Remission at Twelve Months |  | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report |  | |
| 376 | Functional Status Assessment for Total Hip Replacement | ||
| 377 | Functional Status Assessments for Heart Failure | ||
| 378 | Children Who Have Dental Decay or Cavities | ||
| 379 | Primary Caries Prevention Intervention as Offered by Dentists | ||
| 382 | Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | ||
| 384 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery |  | |
| 385 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery |  | |
| 386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences |  | |
| 387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users |  | |
| 389 | Cataract Surgery: Difference Between Planned and Final Refraction |  | |
| 392 | Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation |  | |
| 393 | Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision |  | |
| 394 | Immunizations for Adolescents |  | |
| 395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) |  | |
| 396 | Lung Cancer Reporting (Resection Specimens) |  | |
| 397 | Melanoma Reporting |  | |
| 398 | Optimal Asthma Control |  | |
| 400 | One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation |  | |
| 401 | Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis |  | |
| 404 | Anesthesiology Smoking Abstinence |  | |
| 405 | Appropriate Follow-up Imaging for Incidental Abdominal Lesions |  | |
| 406 | Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients |  | |
| 410 | Psoriasis: Clinical Response to Systemic Medications |  | |
| 413 | Door to Puncture Time for Endovascular Stroke Treatment |  | |
| 415 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older |  | |
| 416 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years |  | |
| 418 | Osteoporosis Management in Women Who Had a Fracture |  | |
| 419 | Overuse of Imaging for the Evaluation of Primary Headache |  | |
| 420 | Varicose Vein Treatment with Saphenous Ablation: Outcome Survey |  | |
| 421 | Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal |  | |
| 422 | Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury |  | |
| 424 | Perioperative Temperature Management |  | |
| 430 | Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy |  | |
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling |  | |
| 432 | Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair |  | |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |  | |
| 440 | Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician |  | |
| 441 | Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) |  | |
| 443 | Non-Recommended Cervical Cancer Screening in Adolescent Females |  | |
| 445 | Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) |  | |
| 448 | Appropriate Workup Prior to Endometrial Ablation |  | |
| 450 | Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer |  | |
| 451 | RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy |  | |
| 453 | Percentage of Patients who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) |  | |
| 457 | Percentage of Patients who Died from Cancer Admitted to Hospice for Less than 3 Days (lower score – better) |  | |
| 459 | Back Pain After Lumbar Surgery |  | |
| 461 | Leg Pain After Lumbar Surgery |  | |
| 462 | Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | ||
| 463 | Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer |  | |
| 464 | Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use |  | |
| 465 | Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries |  | |
| 468 | Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) |  | |
| 470 | Functional Status After Primary Total Knee Replacement |  | |
| 471 | Functional Status After Lumbar Surgery |  | |
| 475 | HIV Screening | ||
| 476 | Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia | ||
| 477 | Multimodal Pain Management |  | |
| 478 | Functional Status Change for Patients with Neck Impairments |  | |
| 481 | Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer | ||
| 482 | Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate |  | |
| 483 | Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) |  | |
| 485 | Improvement in Patient-Reported Itch Severity |  | |
| 486 | Dermatitis – Improvement in Patient-Reported Itch Severity |  | |
| 487 | Screening for Social Drivers of Health |  | |
| 488 | Kidney Health Evaluation |  | |
| 489 | Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy |  | |
| 490 | Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors |  | |
| 491 | Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status |  | |
| 493 | Adult Immunization Status |  | |
| 495 | Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood |  | |
| 496 | Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument |  | |
| 497 | Preventive Care and Wellness (Composite) |  | |
| 498 | Connection to Community Service Provider |  | |
| 499 | Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy |  | |
| 500 | Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up |  | |
| 501 | Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up |  | |
| 502 | Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder |  | |
| 503 | Gains in Patient Activation Measure (PAM) Scores at 12 Months |  | |
| 504 | Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk |  | |
| 505 | Reduction in Suicidal Ideation or Behavior Symptoms |  | |
| 506 | Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy |  | |
| 507 | Appropriate Germline Testing for Ovarian Cancer Patients |  | |
| 508 | Adult COVID-19 Vaccination Status |  | |
| 509 | Melanoma: Tracking and Evaluation of Recurrence |  | |
| 510 | First Year Standardized Waitlist Ratio (FYSWR) |  | |
| 511 | Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW) |  | |
| 1056 | Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level) |
