NJ DSRIP Planning Protocol Addendum 2 - Stage 4 Measures Catalogue
*Definitions and Acronyms are located at the end of this document.
Measure Count / Measure Name / DSRIP # / NQF# / Measure Steward / NJ Data Source / Reporting Entity/ Setting of Care / Reporting Period / Eligible for Universal Performance Pool? / Eligible for or as a Substitution for UPP?
1 / Inpatient Utilization – General Hospital/ Acute Care / 53 / Not Found / NCQA / MMIS / Department/ Inpatient Care / Annual; April / No / No
2 / Mental Health Utilization / 62 / Not Found / NCQA / MMIS / Department/ Inpatient Care, Outpatient Care / Annual; April / No / No
3 / Pneumococcal Immunization (PPV 23) / 72 / 1653 / CMS / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / No / No
4 / Prophylactic Antibiotic Selection for Surgical Patients – Overall Rate / 77 / 0528 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / No / No
5 / Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time – Overall Rate / 78 / 0529 / Joint Commission / Chart/ EHR / Hospital/
Inpatient Care / Annual; April / No / No
6 / Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero / 82 / 0453 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / No / No
7 / Venous Thromboembolism Prophylaxis / 85 / 0371 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / 1st SA = April
2nd SA = October / No / No
8 / Intensive Care Unit Venous Thromboembolism Prophylaxis / 54 / 0372 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / 1st SA = April
2nd SA = October / No / No
9 / Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/ Platelet Count Monitoring by Protocol or Nomogram / 84 / Not Found / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / 1st SA = April
2nd SA = October / No / No
10 / Venous Thromboembolism Warfarin Therapy Discharge Instructions / 86 / Not Found / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / 1st SA = April
2nd SA = October / No / No
11 / Follow-up After Hospitalization for Mental Illness – 7 Days / 41 / 0576 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
12 / Engagement of alcohol and other drug treatment / 38 / 0004 / NCQA / MMIS / Department/ Inpatient Care, Outpatient Care / Annual; April / No / No
13 / Percent of patients who have had a visit to an Emergency Department (ED) office for asthma in the past six months / 66 / Not Found / HRSA / MMIS / Hospital/ Emergency Department / 1st SA = April
2nd SA = October / No / No
14 / Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic* / 56 / 0068 / NCQA / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
15 / Preventive Care and Screening: High Blood Pressure* / 75 / Not Found / AMA-PCPI / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
16 / Controlling High Blood Pressure* / 31 / 0018 / NCQA / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
17 / Comprehensive Diabetes Care: LDL-C Control <100mg/dL* / 30 / 0064 / NCQA / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
18 / Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100mg/dL* / 55 / 0075 / CMS / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
19 / Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention* / 76 / 0028 / AMA-PCPI / Chart/ EHR / DSRIP Network/ Outpatient Care / Annual; April / No / No
20 / Hemoglobin A1C (HbA1c) Testing for Pediatric Patients / 46 / 0060 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
21 / CD4 T-Cell Count / 20 / Not Found / HRSA / MMIS / Department/ Outpatient Care / Annual; April / No / No
22 / Gap in HIV Visits / 44 / 2080 / HRSA / MMIS / Department/ Outpatient Care / Annual; April / No / No
23 / Breast Cancer Screening / 16 / 0031 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
24 / Cervical Cancer Screening / 22 / 0032 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
25 / Chlamydia Screening in Women Age 21 – 24 / 28 / 0033 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
26 / Childhood Immunization Status / 25 / 0038 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
27 / Well-Child Visits in the First 15 Months of Life / 88 / 1392 / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
28 / Children and Adolescents’ Access to Primary Care Practitioners / 27 / Not Found / NCQA / MMIS / Department/ Outpatient Care / Annual; April / No / No
29 / Antenatal Steroids / 10 / 0476 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / No / No
30 / Hospital Acquired Potentially-Preventable Venous Thromboembolism / 47 / Not Found / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / 1st SA = April
2nd SA = October / UPP / No
31 / Asthma in Younger Adults Admission / 14 / 0283 / AHRQ / MMIS / Department/ Inpatient Care / Annual; April / UPP / No
32 / Diabetes Short-Term Complications Admission Rate / 36 / 0272 / AHRQ / MMIS / Department/ Inpatient Care / Annual; April / UPP / No
33 / Ambulatory Care – Emergency Department Visits / 8 / Not Found / NCQA / MMIS / Department/ Emergency Department / Annual; April / UPP / No
34 / COPD Admission Rate / 32 / 0275 / AHRQ / MMIS / Hospital/ Inpatient Care / Annual; April / UPP / No
35 / Heart Failure Admission Rate / 45 / 0277 / AHRQ / MMIS / Hospital/ Inpatient Care / Annual; April / UPP / No
36 / Central Line-Associated Bloodstream Infection (CLABSI) Event / 21 / 0139 / CDC / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / No
37 / Postoperative Sepsis / 74 / Not Found / AHRQ / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / No
38 / Pediatric Central-Line Associated Bloodstream Infections (CLABSI) – Neonatal Intensive Care Unit and Pediatric Intensive Care Unit** / 63 / 0139 / CDC / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
39 / Percentage of Live Births Weighing Less Than 2,500 grams** / 67 / Not Found / CDC / MMIS / Department/ Inpatient Care / Annual; April / UPP / Yes
40 / Cesarean Rate for Nulliparious Singleton Visits** / 23 / Not Found / California Maternal Quality Care Collaborative / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
41 / Elective Delivery** / 37 / 0469 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
42 / 30-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization / 3 / 0330 / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
43 / 30-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization / 1 / 0505 / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
44 / 30-Day All-Cause Readmission Following Pneumonia (PN) Hospitalization / 4 / 0506 / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
45 / 30-Day All-Cause Readmission Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization / 2 / 1891 / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
*This measure is included in the Million Hearts measure list. It may be used as a substitution for a cardiac measure when substitution is required.
**This measure is eligible to be replaced by a UPP substitution measure, but only if your hospital does not perform such services (i.e. inpatient maternity or pediatric services).
Definition Key:
Department–Refers to the New Jersey Department of Health
DSRIP Network– Refers to the DSRIP hospital’s outpatient (non-ED, non-inpatient) reporting entities. This may include the hospital-based clinic (as identified through hospital billing practices) a community-based reporting partner, or a combination of the two.
Hospital – Refers to the participating DSRIP hospital
Inpatient – Refers to the setting where care is received as a result of an admission order to a hospital.
OutpatientCare– Refers to outpatient, (non-ED, non-inpatient) ambulatory care. This may include physical health or behavioral health care.
Acronym Key:
AHRQ – Agency for Healthcare Research and Quality
AMA- PCPI – American Medical Association – Physician Consortium for Performance Improvement
CDC – Centers for Disease Control and Prevention
CMS – Centers for Medicare & Medicaid Services
EHR – Electronic Health Record
HRSA – Health Resources and Services Administration
MMIS – Medicaid Management Information System
NCQA – National Committee for Quality Assurance
UPP – Universal Performance Pool
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