Measure Information Form Introduction

Measure Set

The specific national hospital quality measure set to which an individual measure belongs (e.g., acute myocardial infarction, pneumonia).

Set Measure ID #

A unique alpha-numeric identifier assigned to a measure. Information associated with a measure is identified by this unique alpha-numeric number.

Performance Measure Name

A brief title that uniquely identifies the measure.

Description

A brief explanation of the measure’s focus, such as the activity or the area on which the measure centers attention (e.g., pain management for terminally ill patients)

Rationale

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.

Type of Measure

Indicates whether the measure is used to examine a process or an outcome over time.

• Process: A measure used to assess a goal directed, interrelated series of actions, events, mechanisms, or steps, such as measure of performance that describes what is done to, for, or by patients, as in performance of a procedure.
• Outcome: A measure that indicates the result of performance (or non-performance) of a function(s) or process(es).

Improvement Noted As

Describes how improvement would be indicated by the measure.

• An increase in the rate/score/number of occurrences (for example, immunizations)
• A decrease in the rate/score/number of occurrences (for example, surgical site infections)
• Either an increase or a decrease in the rate/score/number of occurrences, depending upon the context of the measure (for example, utilization)

Numerator Statement

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.

Denominator Statement

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 denominator

Continuous Variable Statement

Describes 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 variable

Risk Adjustment

Indicates whether a measure is subject to the statistical process for reducing, removing, or clarifying the influences of confounding factors to allow more useful comparisons.

Data Collection Approach

Recommended timing for when data should be collected for a measure. Data collection approaches include retrospective, concurrent or prospective data collection. Retrospective data collection involves collecting data for events that have already occurred. Concurrent data collection is the process of gathering data on how a process works or is working while a patient is in active treatment. Prospective data collection is data collection in anticipation of an event or occurrence.

Data Accuracy

Recommendations to reduce identifiable data errors, to the extent possible.

Measure Analysis Suggestions

Recommendations to assist in the process of interpreting data and drawing valid conclusions.

Sampling

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.

Data Reported As

Indicates how data will be reported for a measure.

• Aggregate rate generated from count data reported as a proportion (for example, rate-based measures which report summary data generated from the number of Cesarean sections as a proportion of deliveries)
• Aggregate rate generated from count data reported as a ratio (e.g., bloodstream infection per 1,000 line days).
• Aggregate measures of central tendency (e.g., continuous variables which report means and medians such as length of stay).

Calculation Model

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.

Selected References

Specific literature references that are used to support the importance of the performance measure.

Algorithm Introduction

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:

• For rate-based measures, the patient’s EOC record belongs in the measure population of interest described by the denominator, and if the patient experienced the event described in the numerator.
• For continuous variable measures, the patient’s EOC record belongs in the patient population described in the measure’s statement and, if so, to define and calculate the measurement value.

This section contains some standard flow-charting conventions used to develop each algorithm:

• Flow lines are used to guide the reader to different parts of the algorithm, with arrows denoting the direction of movement. Generally, movement is from the top to the bottom of the chart.
• Symbols used in each algorithm flow charts are described later in this section under Flow Chart Symbols.
• Temporary variables within the algorithm are noted in the variable key at the top of each page.

Flowchart Symbols