Measure Set

The specific certification measure set to which an individual measure belongs (e.g., health care staffing services, stroke).

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.

Rationale

An explanation that states why it is important to receive data/information on this measure. 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, customer satisfaction)
• A decrease in the rate/score/number of occurrences (for example, do not returns)
• 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.

Numerator Inclusions Specific information describing the components: comprising the numerator, not contained in the numerator statement, or not applicable.

Numerator Exclusions Specific information describing the components: that should not be included in the numerator, or none.

Data Elements Those data elements necessary or required to construct the numerator.

Denominator Statement

Represents the population evaluated by the performance measure.

Denominator Inclusions Specific information describing the components: comprising the denominator, not contained in the denominator statement, or not applicable.

Denominator Exclusions Specific information describing the components: that should not be included in the denominator, or none.

Data Elements Those data elements required to construct the denominator

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.

Sampling

Indicates whether a measure is amenable to selecting a random subset of a population in order to estimate the organization’s performance level 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).

Setting

The setting to which the performance measure set applies.

Report Period

The defined time period for data collection.

Selected References

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

Flowchart Symbols

Symbol	Explanation
	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.

Performance Measure Data Report (pdf)

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