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Topics Covered in this section:

  • Chart-abstracted Measures (CAM)

  • Chart-Abstracted Measures for Assisted Living Communities (ALCs)

  • Electronic Clinical Quality Measure (eCQM)

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CHART-ABSTRACTED MEASURES

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titleED-1 Median ED Arrival to ED Departure-Admit (CAM)

Resource Title: American College of Emergency Physicians (ACEP), Emergency Department Crowding: High Impact Solutions

Link: https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

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Resource Title: Source

Link: Hyper Link
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titleHBIPS-2 Hours of Physical Restraint Use (CAM)

Resource Title: Source

Link: Hyper Link

Resource Title: APNA Standards of Practice: Seclusion and Restraint

Link: APNA Standards of Practice: Seclusion and Restraint | APNA

Resource Title: x

Link: x

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titleMeasure Name (TYPE)

Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/

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titleHBIPS-3 Hours of Seclusion Use (CAM)

Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Link: http://apapsy.ch/S-R

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titleIMM-2 Influenza Immunization (CAM)

Resource Title: CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2024-25

Link: https://www.cdc.gov/flu/hcp/acip/index.html

Resource Title: National Adult and Influenza Immunization Summit: Influenza Vaccination Resources

Link: https://www.izsummitpartners.org/influenza-vaccination-resources/

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titleOP-18 Median ED Arrival-ED Departure at Discharge (CAM)

Resource Title: AHRQ Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: American College of Emergency Physicians Approaching Full Capacity in the Emergency Department

Link: https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/crowding/approach_full_capacity.pdf

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titleOP-23 Head CT or MRI Scan Results-Stroke (CAM)

Resource Title: American Heart Association Target: Stroke Direct to CT/MRI Protocol

Link: https://www.heart.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-ii/ts_directtoct_ucm_470723.pdf?la=en&hash=D8E20DFC9A703E20B388E4AAFC204E98ACDF4D53

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titlePC-01 Elective Delivery (CAM)

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://www.qualityforum.org/Publications/2014/08/Playbook_for_the_Successful_Elimination_of_Early_Elective_Deliveries.aspx

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titlePC-02 Cesarean Birth (CAM)

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link:

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

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titlePC-05 Exclusive Human Milk Feeding (CAM)

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit

Link: http://www.usbreastfeeding.org/

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titlePC-06 Unexpected Complications in Term Newborns (CAM)

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) Unexpected Complications in Term Newborns

Link:

Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality

Link: https://www.cdc.gov/maternal-infant-health/infant-mortality/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

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titleSDOH-1 Screening for Social Drivers of Health (CAM)

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

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titleSDOH-2 Screen Positive Rate for Social Drivers of Health (CAM)

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

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titleSUB-2 Alcohol Use Brief Intervention (CAM)

Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment

Link: https://www.samhsa.gov/sbirt

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titleSUB-3 Alcohol & Drug Use Treatment at Discharge (CAM)

Resource Title: The American Psychiatric Association Practice Guideline For The Pharmacological Treatment Of Patients With Alcohol Use Disorder

Link: https://doi.org/10.1176/appi.books.9781615371969

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titleTOB-3 Tobacco Use Treatment at Discharge (CAM)

Resource Title: 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment 

A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents 

Link: https://www.jacc.org/doi/10.1016/j.jacc.2018.10.027

Resource Title: Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities — United States, 2016

Link: https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a3.htm

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Chart-Abstracted Measures for Assisted Living Communities (ALCs)

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titleALC-01 Off-Label Antipsychotic Drug Use

Resource Title: American Geriatrics Society 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

Link: https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.18372

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titleALC-02 Resident Falls

Resource Title: Agency for Healthcare Research and Quality: Long-term Care Resources about Falls and Injuries

Link: https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/index.html

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titleALC-03 Resident Preferences and Goals of Care

Resource Title: Preference Based Living: Tip Sheets for Guidance on Creating a Culture of Preference Based Care

Link: https://www.preferencebasedliving.com/tip-sheets/

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titleALC-04 Advanced Care Plan/Surrogate Decision-Maker

Resource Title: National Institute on Aging: Advance Care Planning

Link: https://www.nia.nih.gov/health/topics/advance-care-planning

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titleALC-05 Staff Stability

Resource Title: American Nurses Association Nurse Retention Strategies: How to Combat Nurse Turnover

Link: https://www.nursingworld.org/content-hub/resources/nursing-leadership/nurse-retention-strategies/

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Electronic Clinical Quality Measures (eCQMs)

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titleeGMCS Global Malnutrition Composite Score

Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources

Link: https://www.cdrnet.org/GMCS

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titleeHH-01 Hospital Harm—Severe Hypoglycemia Measure

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

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titleeHH-02 Hospital Harm—Severe Hyperglycemia Measure

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

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titleeHH-03 Hospital Harm—Opioid Related Adverse Events

Resource Title: Society of Hospital Medicine: Opioid Safety

Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/

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titleeOP-40 ST-Segment Elevation Myocardial Infarction

Resource Title: AHA/ASA Journals: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Link: https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6

Resource Title: AHA/ASA Journals: Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice

Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.120.009179

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titleePC-01 Elective Delivery

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://www.qualityforum.org/Publications/2014/08/Playbook_for_the_Successful_Elimination_of_Early_Elective_Deliveries.aspx

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titleePC-02 Cesarean Birth

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

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titleePC-05 Exclusive Human Milk Feeding

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit

Link: http://www.usbreastfeeding.org/

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titleePC-06 Unexpected Complications in Term Newborns

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) Unexpected Complications in Term Newborns

Link:

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

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titleePC-07 Severe Obstetric Complications

Resource Title: American Hospital Association Maternal and Child Health Tools and Resources

Link: https://www.aha.org/maternal-child-health-tools-resources

Resource Title: Alliance for Innovation on Maternal Health

Link: https://saferbirth.org/

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titleeSTK-2 Discharged on Antithrombotic Therapy

Resource Title: Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/10.1161/str.0000000000000024

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titleeSTK-3 Anticoagulation Therapy Atrial Fibrillation/Flutter

Resource Title: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

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titleeSTK-5 Antithrombotic Therapy by End of Hospital Day 2

Resource Title: x

Link: x

Resource Title:

Link: x

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titleeVTE-1 Venous Thromboembolism Prophylaxis

Resource Title: x

Link: x

Resource Title:

Link: x

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titleeVTE-2 ICU Venous Thromboembolism Prophylaxis

Resource Title: x

Link: x

Resource Title:

Link: x

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titleSafe Use of Opioids

Resource Title: CDC: Overdose Prevention

Link: https://www.cdc.gov/overdose-prevention/index.html

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titlex

Resource Title: x

Link: x

Resource Title:

Link: x