The specific national hospital quality measure set to which an individual measure belongs (e.g., acute myocardial infarction, stroke).
A unique alpha-numeric identifier assigned to a measure. Information associated with a measure is identified by this unique alpha-numeric number.
A brief title that uniquely identifies the measure.
A brief explanation of the measure”s focus, such as the activity or the area on which the measure centers attention (e.g., ischemic stroke patients prescribed antithrombotic therapy at hospital discharge)
The reason for performing a specified process to improve the quality of care outcomes. This may include specific literature references, evidence based information, expert consensus, etc.
Represents the portion of the denominator population that satisfies the conditions of the performance measure to be an indicator event.
Note: If the measure is reported as a rate (proportion or ratio), the Numerator and Denominator Statement are completed. If a performance measure does not have both a numerator and a denominator, then a Continuous Variable Statement is completed.
Included Population in Numerator Specific information describing the population(s) comprising the numerator, not contained in the numerator statement, or not applicable Excluded Population in Numerator Specific information describing the population(s) that should not be included in the numerator, or none Data Elements Those data elements necessary or required to determine (or establish) the numerator.Represents the population evaluated by the performance measure.
Note: If measure is reported as a rate (proportion or ratio), the Numerator and Denominator Statement are completed. If a performance measure does not have both a numerator and a denominator, then a Continuous Variable Statement is completed.
Included Population in Denominator Specific information describing the population(s) comprising the denominator, not contained in the denominator statement or not applicable Excluded Population in Denominator Specific information describing the population(s) that should not be included in the denominator, or none Data Elements Those data elements required to determine (or establish) the denominatorDescribes an aggregate data measure in which the value of each measurement can fall anywhere along a continuous scale.
Note: If measure is reported as a central tendency, Continuous Variable Statement is completed. This item is only completed when the performance measure does not have numerator and denominator statements.
Included Population in Continuous Variable Specific information describing the population(s) comprising the performance measure, not contained in the continuous variable statement or not applicable Excluded Population in Continuous Variable Specific information describing the population(s) that should not be included in the performance measure or none Date Elements Those data elements required to determine (or establish) the measure for a continuous variableIndicates whether a measure is subject to the statistical process for reducing, removing, or clarifying the influences of confounding factors to allow more useful comparisons.
Recommendations to reduce identifiable data errors, to the extent possible.
Recommendations to assist in the process of interpreting data and drawing valid conclusions.
Indicates whether or not a measure can be sampled. Sampling is a process of selecting a representative part of a population in order to estimate the organization's performance, without collecting data for the entire population.
A description of the steps or statistical calculations (computations) used to derive the numerator and denominator or continuous variable values required for a measure. Measure Information Forms in this manual will include either an algorithm or calculation model.
Specific literature references that are used to support the importance of the performance measure.
Each measure's initial patient population and the measure is described by a unique algorithm. An algorithm is a predefined set of rules that help to break down complex processes into simple, repetitive steps.
Measure algorithms serve two purposes. First, they evaluate and identify which episode of care (EOC) records contain missing and/or invalid data that will prohibit the ability to properly evaluate the measure. Second, they determine if:Symbol | Explanation |
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Start/Stop denotes the beginning or end of an algorithm | |
Diamonds represent "If…Then" decision points for logic tests and comparisons. Two or three flow lines exit the decision point to reflect alternative actions based upon an evaluation of the condition(s) stated around the decision point. | |
Rectangles or process boxes show when computation or manipulation of the data are required, such as a calculation or summarization. | |
Circle or "On-page: connectors, labeled with a letter, show a link to sections of the algorithm which are continued on the same page. | |
Five-sided or "Off-page" connectors, labeled with a letter, show a link to sections of the algorithm which are continued on different pages. Note: Both circular, On-page, five-sided, and Off-page Connectors containing the letters B, D, E, U, X, or Y lead to measure Outcome Boxes. | |
Outcome Boxes represent the result of data passed through the algorithm. Connectors extending from outcome boxes lead to the end of the algorithm, or to risk adjustment procedures, where applicable. This symbol is also used to identify the strata within a stratified measure. | |
Symbol to represent comments that should be taken into account when programming flowchart. | |
This symbol is placed along side the Process box to which they are applicable. Comments are used to expand upon information contained within the process box, such as how to properly calculate age. Comments are never the sole location where processing logic is provided. | |
Start/Return denotes the beginning and ending of a sub-routine. Algorithms that use this symbol are called from another algorithm and the data processing flow returns to the calling algorithm when the Return' is encountered. See the Initial Patient Population Algorithms and Transmission Data Processing Flows for an example of the usage of this symbol. |