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Related NGC Guidelines

The list below identifies measures with associated guidelines available through the National Guideline Clearinghouseâ„¢ (NGC) Web site External Web Site Policy.

Pain management: percentage of patients with documented assessment for pain using standardized tool on admission. NQMC:009588

Pain management: percentage of patients with documented assessment for pain using standardized tool at each quarterly review. NQMC:009589

Pain management: percentage of patients with documented assessment for pain using standardized tool at each reported change of condition requiring Minimum Data Set (MDS) assessment. NQMC:009590

Pain management: percentage of patients with cognitive and language deficit receiving targeted pain assessment. NQMC:009591

Pain management: percentage of patients with documented assessment by licensed nurse of a sufficiently detailed evaluation to characterize the pain. NQMC:009592

Pain management: percentage of patients with documentation showing that the practitioner performed laboratory, radiologic, and other diagnostic tests as appropriate. NQMC:009593

Pain management: percentage of patients with documentation by the practitioner that summarizes the characteristics and causes of the patient's pain. NQMC:009594

Pain management: percentage of patients with documented assessment of the impact of pain on function and quality of life. NQMC:009595

Pain management: percentage of patients with documented person-centered inter-professional care plan for acute or chronic pain. NQMC:009596

Pain management: percentage of patients with established set goals for pain relief. NQMC:009597

Pain management: percentage of patients with documented medication regimen with evidence of titration/adjustment in accordance with World Health Organization (WHO) step ladder. NQMC:009598

Pain management: percentage of patients on pain medications with adjunctive (complementary alternative medicine [CAM], physical therapy [PT], etc.) therapies to assist in pain relief. NQMC:009599

Pain management: percentage of patients on opioid medications receiving an appropriate constipation prevention regime. NQMC:009600

Pain management: percentage of patients with periodic documented assessment of effectiveness of pain management by practitioner. NQMC:009601

Pain management: percentage of patients with periodic documented assessment by licensed nursing staff of effectiveness of pain management. NQMC:009602

Pain management: percentage of patients with periodic documented assessment by licensed nursing staff of effectiveness of pain management using same standardized tool used in the original pain assessment. NQMC:009603

Pain management: percentage of patients with adjustments made in treatment plan by practitioner when pain management plan is not effective. NQMC:009604

Pain management: percentage of patients with adverse drug reactions (ADRs) related to pain medications. NQMC:009605

Pain management: percentage of patients with controlled adverse drug reactions (ADRs) to pain medications. NQMC:009606

Pain management: percentage of patients with documented reduction of pain symptoms. NQMC:009607

Pain management: percentage of patients documented with achieving pain control goals after treatment. NQMC:009608

Pain management: percentage of patients with severe opioid-related constipation or fecal impaction. NQMC:009609

Urinary incontinence (UI): percentage of patients whose transfer summary is reviewed for a history of UI on admission. NQMC:009629

Urinary incontinence (UI): percentage of patients observed for current signs or symptoms of UI on admission. NQMC:009630

Urinary incontinence (UI): percentage of patients with onset and type of incontinence identified (to the extent possible) on admission. NQMC:009631

Urinary incontinence (UI): percentage of patients with diagnosed UI whose symptoms are documented by the practitioner in the patient's record. NQMC:009632

Urinary incontinence (UI): percentage of patients assessed for modifiable causes of UI so that interventions may be targeted to those factors. NQMC:009633

Urinary incontinence (UI): percentage of patients who have received a physical examination and workup as indicated for UI. NQMC:009634

Urinary incontinence (UI): percentage of patients with UI who have had their relevant information summarized. NQMC:009635

Urinary incontinence (UI): percentage of patients with UI with individualized treatment goals and plans of care. NQMC:009636

Urinary incontinence (UI): percentage of patients with addressed transient causes of UI. NQMC:009637

Urinary incontinence (UI): percentage of patients with addressed modifiable risk factors of UI. NQMC:009638

Urinary incontinence (UI): percentage of patients with UI who are appropriate for a toileting program that have one. NQMC:009639

Urinary incontinence (UI): percentage of patients who have failed on nonpharmacologic interventions and are then evaluated for pharmacologic treatment. NQMC:009640

Urinary incontinence (UI): percentage of patients with an indwelling catheter with documented medical justification. NQMC:009641

Urinary incontinence (UI): percentage of patients whose response to treatment for UI is monitored and documented in the patient's medical record. NQMC:009642

Urinary incontinence (UI): percentage of patients with UI whose response to the current treatment plan indicates a need for reassessment and receives such reassessment. NQMC:009643

Urinary incontinence (UI): percentage of patients who are being monitored for side effects of medications prescribed for the treatment of UI. NQMC:009644

Urinary incontinence (UI): percentage of patients experiencing complications as a result of an indwelling catheter (such as pain, bleeding, blockage, or urosepsis). NQMC:009645

Urinary incontinence (UI): percentage of patients with unnecessary indwelling catheters. NQMC:009646

Urinary incontinence (UI): percentage of patients being treated for UI that show resolution/improvement of signs and symptoms of UI. NQMC:009647

Urinary incontinence (UI): percentage of patients utilizing appropriate continence products (such as those that are comfortable and wick wetness away from skin, promote and maintain a healthy skin environment, and are conducive to dignity). NQMC:009648

Urinary incontinence (UI): percentage of patients with UI who have had nonessential anticholinergic medications discontinued to reduce the overall anticholinergic load. NQMC:009649

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD, with evidence that they met the DSM-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified. NQMC:010195

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a diagnosis of MDD who received patient education at least once during the measurement period, regarding the minimum specified criteria. NQMC:010196

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a diagnosis of MDD who have a depression severity classification and who receive, at a minimum, treatment appropriate to their depression severity classification at the most recent visit during the measurement period. NQMC:010197

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD with three follow-up visits in the first 90 days following diagnosis of a new or recurrent episode of MDD. NQMC:010198

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD with documentation of the patient's response to treatment three times in the first 90 days following diagnosis, and, if patient has not improved, documentation of treatment plan review or alteration. NQMC:010199

Major depressive disorder (MDD): percentage of medical records of patients aged 18 years and older with a diagnosis of MDD and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], ESRD or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition. NQMC:010200

Diagnostic flexible bronchoscopy: proportion of adults with suspected lung cancer or requiring an urgent bronchoscopy having bronchoscopy within 7 working days of the decision to perform bronchoscopy. NQMC:010942

Diagnostic flexible bronchoscopy: proportion of adults undergoing bronchoscopy who suffer a serious adverse event. NQMC:010943

Diagnostic flexible bronchoscopy: proportion of bronchoscopy procedures performed with a completed safety checklist. NQMC:010944

Diagnostic flexible bronchoscopy: proportion of patients who are managed according to the trust's sedation policy. NQMC:010945

Diagnostic flexible bronchoscopy: proportion of bronchoscopies done with the appropriate number, skill mix and competence of staff. NQMC:010946

Diagnostic flexible bronchoscopy: proportion of bronchoscopy procedures performed with evidence of correct decontamination. NQMC:010947

Diagnostic flexible bronchoscopy: proportion of bronchoscopy procedures performed with adequate tracking of bronchoscope and accessories. NQMC:010948

Diagnostic flexible bronchoscopy: proportion of patients with a definite visible endobronchial tumour correctly diagnosed during bronchoscopy tissue sampling (histology and/or cytology specimens). NQMC:010949

Diagnostic flexible bronchoscopy: proportion of patients diagnosed with malignancy where sufficient tissue was obtained for genetic profiling/all tissue sent for profiling. NQMC:010950

Diagnostic flexible bronchoscopy: proportion of adults with suspected lung malignancy having computed tomography (CT) scans reported prior to bronchoscopy. NQMC:010951

Diagnostic flexible bronchoscopy: proportion of adults undergoing bronchoscopy where patient consent was taken and recorded in the clinical record. NQMC:010952

Diagnostic flexible bronchoscopy: proportion of patients having a flexible bronchoscopy in the unit per year who completed surveys. NQMC:010953

Diagnostic flexible bronchoscopy: proportion of patients with confirmed diagnosis of lung cancer who underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) sampling for diagnosis/staging who were diagnosed and accurately staged by EBUS-TBNA sampling. NQMC:010954

Diagnostic flexible bronchoscopy: proportion of patients with confirmed lung cancer where genotyping was appropriately requested from endobronchial ultrasound (EBUS) sampling where sufficient tissue for genotyping was obtained. NQMC:010955

Diagnostic flexible bronchoscopy: proportion of patients with non small cell lung cancer diagnosis confirmed from endobronchial ultrasound (EBUS) sampling with non small cell lung cancer, not otherwise specified (NSCLC NOS) diagnosed from EBUS sampling. NQMC:010956

Diagnostic flexible bronchoscopy: proportion of patients who had endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) sampling and suffer a complication as a result of the procedure. NQMC:010957

Diagnosis of breast disease: percentage of BI-RADS category 4 or BI-RADS category 5 mammograms that are followed by a biopsy within 7 to 10 days. NQMC:007433

Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have all of the following at the initial visit with the physician: pain assessment using the Visual Analog Scale, pain diagram or other assessment tool; functional status using the Oswestry Disability Questionnaire or other assessment tool; patient history, including notation of presence or absence of "red flags"; assessment of prior treatment and response; job and activity association; and psychosocial screening that includes depression and chemical dependency screening. NQMC:007511

Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have a reassessment at each follow-up visit that includes: pain assessment using the Visual Analog Scale, pain diagram or other assessment tool; functional status using the Oswestry Disability Questionnaire or other assessment tool; clinician's objective assessment; and psychosocial screening that includes depression and chemical dependency screening. NQMC:007512

Adult acute and subacute low back pain: percentage of patients with a diagnosis of non-specific back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flags." NQMC:007513

Adult acute and subacute low back pain: percentage of patients with non-specific back pain diagnosis who received inappropriate repeat imaging studies in the absence of "red flags" or progressive symptoms. NQMC:007514

Adult acute and subacute low back pain: percentage of patients with radicular pain for whom the clinician ordered imaging studies during the six weeks after pain onset. NQMC:007515

Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who are prescribed opioids. NQMC:007518

Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have their functional status assessed using the Oswestry Disability Questionnaire or other assessment tool. NQMC:007519

Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have their pain status assessed using the Visual Analog Scale, pain diagram or other assessment tool. NQMC:007520

Adult acute and subacute low back pain: percentage of patients with non-specific low back pain diagnosis who have had collaborative decision-making with regards to referral to a specialist. NQMC:007521

Adult acute and subacute low back pain: percentage of patients with radicular pain diagnosis who have had collaborative decision-making with regards to imaging, intervention and/or surgery. NQMC:007522

Routine prenatal care: percentage of pregnant patients who have an initial risk assessment completed within two visits of initiation of prenatal care. NQMC:008027

Routine prenatal care: percentage of patients planning pregnancy who have preconception risk assessment/counseling. NQMC:008028

Routine prenatal care: percentage of patients planning a pregnancy who receive counseling and education before pregnancy according to the guideline. NQMC:008029

Routine prenatal care: percentage of pregnant patients who receive counseling and education at each visit as outlined in the guideline. NQMC:008030

Routine prenatal care: percentage of pregnant patients who receive counseling about aneuploidy screening in the first trimester. NQMC:008031

Routine prenatal care: percentage of VBAC-eligible pregnant patients who have a collaborative conversation with their clinician about the risks and benefits of VBAC. NQMC:008032

Routine prenatal care: percentage of patients who have had identified preterm birth (PTB) modifiable risk factors who receive an intervention. NQMC:008033

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of AMI patients who receive a statin agent within 24 hours of arrival and at discharge from hospital for whom treatment is appropriate. NQMC:008330

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with AMI who are referred to an appropriate cardiac rehabilitation program post-discharge. NQMC:008331

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with AMI with referral to an appropriate cardiac rehabilitation program (Phase 2 or Phase 3) post-discharge who enroll in the program. NQMC:008332

Adult acute and subacute low back pain: percentage of patients who were advised on maintenance or resumption of activities, against bed rest, use of heat, education on importance of active lifestyle and exercise, and recommendation to take anti-inflammatory or analgesic medication in the first six weeks of pain onset in the absence of "red flags." NQMC:008333

Non-OR procedural safety: percentage of wrong invasive or high-risk procedure events outside of the operating room per month. NQMC:008432

Non-OR procedural safety: percentage of invasive or high-risk procedures outside of the operating room that met observational compliance. NQMC:008433

Diagnosis and treatment of headache: percentage of patients diagnosed with primary headache using the appropriate diagnostic criteria. NQMC:008573

Diagnosis and treatment of headache: percentage of patients with a primary headache who received educational materials on headache. NQMC:008574

Diagnosis and treatment of headache: percentage of patients with migraine headache who are showing improvement in functional status shown by using one of the following disease-specific tools or questionnaires (e.g., MIDAS, Headache Impact Test [HIT], Migraine Specific Quality of Life [MSQ]). NQMC:008576

Diagnosis and treatment of headache: percentage of patients with primary headache syndrome who are prescribed prophylactic treatment when appropriate. NQMC:008575

Diagnosis and treatment of headache: percentage of patients with migraine headache seen for migraine in the emergency department/urgent care. NQMC:008577

Diagnosis and treatment of headache: percentage of patients with decreased migraine headache shown by using a calendar or diary. NQMC:008578

Diagnosis and treatment of headache: percentage of patients with migraine headache with treatment plans. NQMC:008579

Diagnosis and treatment of headache: percentage of patients with migraine headache with a treatment plan who report adherence to their treatment plan. NQMC:008580

Diagnosis and treatment of headache: percentage of patients with migraine headache with a prescription for opiates or barbiturates for the treatment of migraine. NQMC:008581

Diagnosis and treatment of headache: percentage of patients with migraine headache prescribed appropriate acute treatment. NQMC:008582

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with a viral upper-respiratory infection who do not receive an antibiotic. NQMC:008583

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients and/or parents of children with a viral upper-respiratory infection who receive home treatment education. NQMC:008584

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with strep pharyngitis who had a rapid group A strep test or strep culture. NQMC:008585

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with strep pharyngitis prescribed first-line medications for strep pharyngitis. NQMC:008587

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with strep pharyngitis, and prescribed antibiotics, who had a negative culture or no rapid group A strep test or strep culture. NQMC:008586

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with strep pharyngitis prescribed antibiotics with documentation of education on 24-hour treatment prior to returning to work, school or day care. NQMC:008588

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with strep pharyngitis prescribed antibiotics with documentation of being educated on taking the complete course. NQMC:008589

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with strep pharyngitis instructed on actions to take if symptoms worsen. NQMC:008590

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients diagnosed with seasonal allergic rhinitis being treated with injectable corticosteroids. NQMC:008591

Management of labor: percentage of patients with preterm labor who received antenatal corticosteroids prior to delivery. NQMC:008644

Management of labor: percentage of patients with protracted labor who are administered oxytocin. NQMC:008645

Management of labor: percentage of patients who are assessed for risk status on entry to labor and delivery. NQMC:008646

Management of labor: percentage of patients whose oxytocin is discontinued. NQMC:008647

Management of labor: percentage of patients who have an IV fluid bolus administered. NQMC:008648

Management of labor: percentage of patients whose position is changed to the left or right side to decrease compression of vena cava. NQMC:008649

Stable coronary artery disease: percentage of patients with stable coronary artery disease who are prescribed aspirin and anti-atherosclerotic medications. NQMC:008857

Stable coronary artery disease: percentage of patients with stable coronary artery disease who have demonstrated an understanding of how to respond in an acute cardiac event by "teaching back" as to how they would respond in the case of acute cardiac event. NQMC:008858

Stable coronary artery disease: percentage of patients who smoke with documentation in the medical record that advice to quit was provided and/or help to quit was provided. NQMC:008859

Stable coronary artery disease: percentage of patients with cardiovascular disease who received an annual influenza vaccination. NQMC:008860

Stable coronary artery disease: percentage of patients with documentation in the medical record of receiving a pneumonia vaccination according to the CDC recommendations. NQMC:008861

Stable coronary artery disease: percentage of patients with documentation in the medical record of physical activity goal and when the goal was met. NQMC:008862

Stable coronary artery disease: percentage of patients who were screened for depression using the PHQ-9. NQMC:008863

Stable coronary artery disease: percentage of patients with documentation in the medical record that an LDL was obtained within the last 12 months with an LDL less than 100 mg/dL. Consider less than 70 mg/dL for high-risk patient. NQMC:008864

Stable coronary artery disease: percentage of patients with a documented blood pressure in the medical record of 140/90 mmHg or less. NQMC:008865

Stable coronary artery disease: percentage of patients with diabetes with a documented HbA1c of less than 7.0% or meeting the patient's individualized HbA1c goal. NQMC:008866

Stable coronary artery disease: percentage of patients with diagnosis of stable coronary artery disease with systolic CHF (ejection fraction less than or equal to 40%) who are prescribed an ACE inhibitor or ARB. NQMC:008867

Stable coronary artery disease: percentage of patients with a diagnosis of stable coronary artery disease and chronic kidney disease who are prescribed an ACE inhibitor or ARB. NQMC:008868

Stable coronary artery disease: percentage of patients with a diagnosis of stable coronary artery disease and hypertension who are prescribed an ACE inhibitor or ARB. NQMC:008869

Stable coronary artery disease: percentage of patients with documentation in the medical record of prognostic assessment preceding or following a course of pharmacologic therapy. NQMC:008870

Prevention and management of obesity for adults: percentage of patients who have an annual BMI measured and documented. NQMC:008871

Prevention and management of obesity for adults: percentage of patients with a BMI greater than or equal to 25 who received education and counseling for weight management strategies that include nutrition, physical activity, lifestyle changes, medication therapy and/or surgical considerations. NQMC:008872

Prevention and management of obesity for adults: percentage of patients with a BMI greater than or equal to 25 who have reduced their weight by 5%. NQMC:008873

Prevention and management of obesity for adults: percentage of patients with BMI greater than or equal to 25 who have 30 minutes of any type of physical activity five times per week documented. NQMC:008874

Prevention and management of obesity for adults: percentage of patients with a BMI greater than or equal to 25 who have reduced their weight by 10%. NQMC:008875

Prevention and management of obesity for adults: percentage of patients with a BMI greater than or equal to 40 who have been provided with a referral to a bariatric specialist. NQMC:008876

Heart failure in adults: percentage of patients with heart failure diagnosis and LVSD who at the last clinic visit met the following (if eligible): prescribed or were on ACEI/ARB, prescribed or were on beta-blocker therapy, and a non-smoker. NQMC:008933

Heart failure in adults: percentage of patients with heart failure diagnosis who were educated on the management of their condition. NQMC:008934

Heart failure in adults: percentage of patients with heart failure diagnosis who have a follow-up appointment with their primary care clinician within seven days of hospital discharge. NQMC:008935

Heart failure in adults: percentage of heart failure patients who are current smokers or tobacco users who received smoking cessation advice or counseling in primary care. NQMC:008936

Prevention and management of obesity for children and adolescents: percentage of patients who have an annual BMI measured. NQMC:008964

Prevention and management of obesity for children and adolescents: percentage of patients with BMI screening whose BMI percentile is between 85 and 94. NQMC:008965

Prevention and management of obesity for children and adolescents: percentage of patients with BMI screening whose BMI percentile is greater than or equal to 95. NQMC:008966

Prevention and management of obesity for children and adolescents: percentage of patients with BMI screening who have received education regarding weight management strategies that include nutrition and physical activity. NQMC:008967

Prevention and management of obesity for children and adolescents: percentage of patients with BMI screening percentile greater than or equal to 85 who have cholesterol screening. NQMC:008968

Prevention and management of obesity for children and adolescents: percentage of patients with BMI screening percentile greater than or equal 85 whose BMI percentile decreased within 12 months of screening. NQMC:008969

Preventive services for children and adolescents: percentage of patients who by age 13 years were up-to-date with recommended adolescent immunizations: 1) one HPV – human papillomavirus vaccine by age 13, 2) one MCV4 – meningococcal, 3) one Tdap – tetanus, diphtheria toxoids and acellular pertussis vaccine, and 4) one influenza vaccine within the last year. NQMC:009145

Preventive services for children and adolescents: percentage of sexually active women age 25 years and younger who have had screening for chlamydia. NQMC:009146

Preventive services for children and adolescents: percentage of newborns who have had neonatal screening for hemoglobinopathies, phenylketonuria and hypothyroidism in the first week of life. NQMC:009147

Preventive services for children and adolescents: percentage of patients age five years and younger who have had vision impairment screening. NQMC:009148

Diagnosis and treatment of osteoporosis: percentage of patients who were assessed for risk factors for osteoporosis during an annual preventive visit. NQMC:009321

Diagnosis and treatment of osteoporosis: percentage of patients who were found to be at risk for bone loss or fractures who had bone densitometry. NQMC:009322

Diagnosis and treatment of osteoporosis: percentage of patients with whom adequacy of vitamin D and calcium dietary supplementation were addressed. NQMC:009323

Diagnosis and treatment of osteoporosis: percentage of patients diagnosed with osteoporosis who are on pharmacologic therapy. NQMC:009324

Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture who were assessed for osteoporosis. NQMC:009325

Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture assessed for secondary causes of osteoporosis. NQMC:009326

Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture and diagnosed with osteoporosis due to secondary causes offered treatment. NQMC:009327

Diagnosis and treatment of osteoporosis: percentage of patients with a low-impact (fragility) fracture who are taking calcium and vitamin D dietary supplementation. NQMC:009328

Palliative care for adults: percentage of adult patients with a serious illness who have been screened for palliative care. NQMC:009347

Palliative care for adults: percentage of clinicians who have education and training regarding palliative care concepts. NQMC:009348

Palliative care for adults: percentage of clinicians who have training in the use of scripting for palliative care discussions. NQMC:009349

Palliative care for adults: percentage of adult patients with a serious illness who have been assessed for the domains of palliative care. NQMC:009350

Palliative care for adults: percentage of adult patients with a serious illness who have a symptom assessment documented in the medical record. NQMC:009351

Palliative care for adults: percentage of patients who have treatment options, patient goals and a plan of care across care continuum documented. NQMC:009352

Palliative care for adults: percentage of adult patients with a serious illness who have a revised, documented care plan that addresses the domains of palliative care. NQMC:009353

Palliative care for adults: percentage of adult patients with a serious illness who have a revised symptom assessment in the medical record. NQMC:009354

Palliative care for adults: percentage of adult patients with a serious illness who have documentation in the medical record of a completed advance directive. NQMC:009355

Palliative care for adults: percentage of adult patients with a serious illness who have a completed Physician/Provider Order for Life-Sustaining Treatment (POLST) form documented in the medical record. NQMC:009356

Perioperative protocol: percentage of patients undergoing elective non-high-risk surgery with a preoperative basic health assessment completed prior to the day of the scheduled procedure. NQMC:009651

Perioperative protocol: percentage of patients undergoing elective non-high-risk surgery having laboratory tests/imaging unrelated to positive findings on preoperative basic health assessment. NQMC:009652

Perioperative protocol: percentage of patients undergoing cataract surgery who have electrocardiograms performed as part of the preoperative assessment prior to cataract surgery. NQMC:009653

Perioperative protocol: percentage of patients with comorbidities undergoing elective non-high-risk surgery who have appropriate management of comorbidities prior to surgery, including antithrombotic therapy, recent coronary stent/antiplatelet therapy, beta-blocker therapy, diabetes mellitus, sleep apnea, and nicotine cessation. NQMC:009654

Perioperative protocol: percentage of patients with comorbidities undergoing elective non-high-risk surgery who have preoperative recommendations documented/communicated to the patient and/or surgical facility for all of the following applicable comorbidities: antithrombotic therapy, recent coronary stent/antiplatelet therapy, beta-blocker therapy, diabetes mellitus, sleep apnea, and nicotine cessation. NQMC:009655

Perioperative protocol: percentage of patients with comorbidities who have preoperative education documented for all specified applicable comorbidities. NQMC:009656

Perioperative protocol: percentage of patients who have canceled or delayed non-high-risk surgical procedures due to incomplete preoperative basic health assessment documentation. NQMC:009657

Perioperative protocol: percentage of canceled or delayed surgical procedures due to ineffective communication regarding patient information as defined by organizational procedures. NQMC:009658

Perioperative protocol: percentage of wrong surgery events per month. NQMC:009659

Perioperative protocol: percentage of unintentionally retained foreign objects in surgical cases per month. NQMC:009660

Perioperative protocol: percentage of preoperative wound infections by wound classifications: Class I: clean, Class II: clean contaminated, and Class III: contaminated. NQMC:009661

Perioperative protocol: percentage of surgical patients with documentation of preoperative verification of correct patient, procedure and site/side/level. NQMC:009662

Perioperative protocol: percentage of appropriate surgical patients who had their site marked by the surgeon in preoperative with his/her initials. NQMC:009663

Perioperative protocol: percentage of surgical cases in which a verbal, active Time-Out has been conducted by all appropriate members of the surgical team prior to incision. NQMC:009664

Perioperative protocol: percentage of surgical cases where the baseline count was conducted prior to the patient arriving in the operating/procedure room. NQMC:009665

Perioperative protocol: percentage of surgical cases where counts were not reconciled and imaging was performed. NQMC:009666

Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults: percentage of patients ages 18 to 75 years old with T2DM who are optimally managed, according to the specified components. NQMC:009706

Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults: percentage of patients ages 18 to 75 years old with T2DM with poorly controlled glucose or any of the specified cardiovascular risk factors. NQMC:009712

Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults: percentage of newly diagnosed patients who are advised about lifestyle modification and nutrition therapy within one year of diagnosis. NQMC:009713

Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults: percentage of patients ages 40 to 75 years old with untreated LDL greater than 70 mg/dL who are prescribed statin therapy. NQMC:009714

Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults: percentage of patients with established ASCVD with documented aspirin use. NQMC:009715

Preventive services for adults: percentage of patients age 18 years and older who are screened for risky/harmful alcohol use and/or abuse. NQMC:009970

Preventive services for adults: percentage of women ages 21 to 64 years who have screening for cervical cancer (Pap test) every three years. NQMC:009974

Preventive services for adults: percentage of adolescent girls and women age 21 and younger who undergo cervical cancer screening. NQMC:009980

Preventive services for adults: percentage of women ages 65 to 70 who are screened for cervical cancer and have undergone appropriate screening 10 years prior. NQMC:009981

Hypertension diagnosis and treatment: percentage of patients age greater than or equal to 60 years diagnosed with hypertension whose blood pressure is at SBP less than 150 mmHg and DBP less than 90 mmHg. NQMC:010055

Hypertension diagnosis and treatment: percentage of adult patients age less than 60 years diagnosed with hypertension whose blood pressure is at SBP less than 140 mmHg and DBP less than 90 mmHg. NQMC:010056

Hypertension diagnosis and treatment: percentage of adult patients age greater than or equal to 18 years diagnosed with chronic kidney disease whose blood pressure is at SBP less than 140 mmHg and DBP less than 90 mmHg. NQMC:010057

Hypertension diagnosis and treatment: percentage of adult patients age greater than or equal to 18 years diagnosed with diabetes whose blood pressure is at SBP less than 140 mmHg and DBP less than 90 mmHg. NQMC:010058

Hypertension diagnosis and treatment: percentage of adult patients age greater than or equal to 18 years diagnosed with hypertension who are not at goal for hypertension and have received counseling on diet and physical activity in the past 12 months. NQMC:010059

Adult depression in primary care: percentage of patients with a diagnosis of major depression or persistent depressive disorder with documentation of DSM-5 criteria at the time of the diagnosis. NQMC:010774

Adult depression in primary care: percentage of patients who commit suicide at any time while managed in primary care. NQMC:010775

Adult depression in primary care: percentage of patients who are screened for substance use disorders with an appropriate screening tool. NQMC:010776

Adult depression in primary care: percentage of patients with type 2 diabetes with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9. NQMC:010777

Adult depression in primary care: percentage of patients with cardiovascular disease with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9. NQMC:010778

Adult depression in primary care: percentage of patients who had a stroke with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9. NQMC:010779

Adult depression in primary care: percentage of patients with chronic pain with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9. NQMC:010780

Adult depression in primary care: percentage of perinatal patients with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9. NQMC:010781

Adult depression in primary care: percentage of patients with major depression or persistent depressive disorder whose primary care records show documentation of any communication between the primary care clinician and the mental health care clinician. NQMC:010782

Adult depression in primary care: percentage of patients who have had a response to treatment at six months (+/- 30 days) after diagnosis or initiating treatment, e.g., had a PHQ-9 score decreased by 50% from initial score at six months (+/- 30 days). NQMC:010783

Adult depression in primary care: percentage of patients who have reached remission at six months (+/- 30 days) after diagnosis or initiating treatment, e.g., had any PHQ-9 score less than 5 at six months (+/- 30 days). NQMC:010784

Adult depression in primary care: percentage of patients of patients who have had a response to treatment at 12 months (+/- 30 days) after diagnosis or initiating treatment, e.g., had a PHQ-9 score decreased by 50% from initial score at 12 months (+/- 30 days). NQMC:010785

Adult depression in primary care: percentage of patients who reached remission at 12 months (+/- 30 days) after diagnosis or initiating treatment, e.g., had a PHQ-9 score less than 5 at 12 months (+/- 30 days). NQMC:010786

Adult depression in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (PHQ-9) at six months (+/- 30 days) after diagnosis or initiating treatment. NQMC:010787

Adult depression in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as PHQ-9) at 12 months (+/- 30 days) after diagnosis or initiating treatment. NQMC:010788

Heart failure: percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF less than 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at each hospital discharge. NQMC:010801

Heart failure: percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior left LVEF less than 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting or at each hospital discharge. NQMC:010802

Chronic stable coronary artery disease: percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI or a current or prior LVEF less than 40% who were prescribed beta-blocker therapy. NQMC:010803

Pediatric kidney disease: percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding advance care planning. NQMC:007458

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