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Aim
| Sub Aim |
| Setting |
| QIN-QIO Measures |
| Measures ID |
| Require submission by providers? |
| Require submission by QIN-QIO contractor? |
| Baseline Period |
| Advancing Healthcare Quality Through Technology |
| Advancing access and use of Health IT and interoperability for improving quality and outcomes |
| Multiple Settings (All) |
| Percentage of providers advancing readiness tiers across settings |
| Not applicable |
| No |
| Yes |
| TBD |
| Behavioral Health |
| Chronic Pain |
| Outpatient Clinician |
| (Placeholder for QMVIG) |
| Not applicable |
| Not immediately |
| Not immediately |
| TBD |
| Behavioral Health |
| Depression and Suicide |
| Acute Care Hospital |
| Providing Caring Contacts in ED (including rural emergency hospitals) |
| 1747 - Follow up contacts within 48 hours of a hospital admissions, hospital discharges, or emergency department visits - Active (01747-01-C-DEMO/IAH) |
| Yes |
| Reliability only |
| TBD |
| Behavioral Health |
| Depression and Suicide |
| Acute Care Hospital |
| Safety Planning in ED (including rural emergency hospitals) (Placeholder) |
| Not applicable |
| Not immediately |
| Not immediately |
| TBD |
| Behavioral Health |
| Depression and Suicide |
| Nursing Home |
| Percent Long-Stay Residents with Depressive Symptoms |
| 522 - Percent of Residents Who Have Depressive Symptoms (LS) - Active (00522-01-C-NHQI) |
| No |
| No |
| TBD |
| Behavioral Health |
| Depression and Suicide |
| Outpatient Clinician |
| Preventative Care and Screening: Screening for Depression Follow-up Plan |
| 672 - Preventive Care and Screening: Screening for Depression and Follow-Up Plan - Active (00672-07-E-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Behavioral Health |
| Depression and Suicide |
| Outpatient Clinician |
| Adult Major Depressive Disorder: Suicide Risk Assessment |
| 30 - Adult Major Depressive Disorder (MDD): Suicide Risk Assessment - Active (00030-02-E-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Behavioral Health |
| Substance Use Disorders - Opioids, Alcohol and Polysubstance Abuse |
| Acute Care Hospital |
| Follow-up After ED Visit for Alcohol and Other Drug Use or Dependence |
| 264 - (00264-02-C-MACS) Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence: Age 18 and Older (FUA-AD) - Active |
| No |
| No |
| TBD |
| Behavioral Health |
| Substance Use Disorders - Opioids, Alcohol and Polysubstance Abuse |
| Outpatient Clinician |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling |
| 597 - Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling - Active (00597-02-C-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Care Coordination |
| ED Utilization |
| Nursing Home |
| ED Visits Among Short-Stay and Long-Stay Nursing Home Residents |
| 547 - (00547-01-C-NHQI) Percentage of short-stay residents who have had an outpatient emergency department (ED) visit - Active |
| No |
| No |
| TBD |
| Care Coordination |
| ED Utilization |
| Outpatient Clinician |
| ED Visits per 1,000 Medicare Beneficiaries |
| Not applicable |
| No |
| No |
| TBD |
| Care Coordination |
| Hospital 30-Day Readmissions |
| Acute Care Hospital |
| Hospital 30-Day Readmissions (HWR) All Cause Unplanned |
| 356 - Hospital-Wide 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Hospitalization - Active |
| No |
| No |
| TBD |
| Care Coordination |
| Readmissions to Hospitals from SNF |
| Nursing Home |
| Readmissions to Hospitals from SNF |
| 575 - Potentially Preventable 30-Day Post-Discharge Readmission Measure (00575-03-C-SNFQRP) |
| No |
| No |
| TBD |
| Care Coordination |
| Hospital 30-Day Readmissions |
| Outpatient Clinician |
| 30-Day Readmissions (HWR) All Cause Unplanned |
| 356 - Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups - Active (00356-09-C-MIPS) |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Resulting from emergency preparedness requirements |
| Multiple Settings (NH & ACH) |
| Reduction in median summed severity score (placeholder) |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Related to the 4 Aims |
| Acute Care Hospital |
| Number of hospitals with a summed severity score >5 among those identified for QIN-QIOs because of deficiencies |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Related to the 4 Aims |
| Acute Care Hospital |
| Reduction in median summed severity score |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Related to the 4 Aims |
| Nursing Home |
| Number of nursing homes with a summed severity score >22 among those identified for QIN-QIOs because of deficiencies |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Related to the 4 Aims |
| Nursing Home |
| Reduction in median summed severity score |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Emergency Preparedness & Quality Management Infrastructure |
| Inspection Deficiencies Resulting from QAPI requirements |
| Multiple Settings (NH & ACH) |
| Reduction in summed severity score (placeholder) |
| Not applicable: QSOG, not QMVIG |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Adverse Drug Events (ADE) |
| Acute Care Hospital |
| Safe use of Opioids—Concurrent Prescribing |
| 669 - Safe Use of Opioids - Concurrent Prescribing - Active (00669-01-E-HIQR) |
| Yes |
| Reliability only |
| TBD |
| Patient Safety |
| Prevent Adverse Drug Events (ADE) |
| Nursing Home |
| ADE Among High-Risk Medicare Beneficiaries in NHs |
| QIO-defined measure. Digmann R, Thomas A, Peppercorn S, Ryan A, Zhang L, Irby K, Brock J. Use of Medicare Administrative Claims to Identify a Population at High Risk for Adverse Drug Events and Hospital Use for Quality Improvement. J Manag Care Spec Pharm. 2019 Mar;25(3):402-410. |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Adverse Drug Events (ADE) |
| Nursing Home |
| Antipsychotic Medication Use |
| 526 - Percent of Residents Who Received an Antipsychotic Medication (LS)/(SS) - Active (00526-01-C-NHQI)/(01183-01-C-NHQI) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Adverse Drug Events (ADE) |
| Nursing Home |
| No drug regimen review (short-stay residents only) |
| 225 - Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) - Active (00225-01-C-IRFQR) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Adverse Drug Events (ADE) |
| Outpatient Clinician |
| ADE Among High-Risk Medicare Beneficiaries |
| Not applicable |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Acute Care Hospital |
| Catheter-Associated Urinary Tract Infection (CAUTI) |
| 459 - National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure - Active |
(00459-01-C-HIQR)
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Acute Care Hospital |
| Central Line Associated Bloodstream Infection (CLABSI) |
| 460 - National Healthcare Safety Network (NHSN) Central Line Associated Bloodstream Infection (CLABSI) Outcome Measure - Active (00460-01-C-PCHQR) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Acute Care Hospital |
| Facility-Wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia |
| 463 - National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure - Active |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Acute Care Hospital |
| Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) |
| 462 - National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure - Active (00462-01-C-HACRP) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Acute Care Hospital |
| Harmonized Procedure Specific Surgical Site Infection (SSI) |
| 1 - Surgical Site Infection (SSI) - Active (00001-01-C-MIPS) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Hospital-Associated Infections (HAI) |
| Nursing Home |
| Skilled Nursing Facility HAI Requiring Hospitalization |
| 680 - Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization - Active |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Acute Care Hospital |
| Hospital Harm-Pressure Injuries |
| 341 - Hospital Harm - Pressure Injury - Inactive (00341-01-E-HIQR) |
(00341-01-E-PI) Hospital Harm - Pressure Injury - Inactive
| Patient Safety |
| Prevent Other Adverse Effects |
| Acute Care Hospital |
| Patient Safety Index (PSI)-90: Transitional to Measure in Development |
| 135 - CMS Patient Safety and Adverse Events Composite (CMS PSI 90) - Active (00135-02-C-HACRP) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Acute Care Hospital |
| Median Time from ED Arrival to Departure |
| 427 - Median time from ED Arrival to ED Departure for Discharged ED patients - Active (00427-01-C-HOQR) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Nursing Home |
| Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) |
| 520 - Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) - Active (00520-02-C-LTCHQR) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Nursing Home |
| Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury |
| 121 - Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury - Active (00121-01-C-LTCHQR) |
| No |
| No |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Outpatient Clinician |
| Falls Risk Assessment |
| 256 - Falls: Risk Assessment - Inactive |
| Yes |
| Reliability only |
| TBD |
| Patient Safety |
| Prevent Other Adverse Effects |
| Outpatient Clinician |
| Falls Plan of Care |
| 255 - Falls: Plan of Care - Active (00255-02-C-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Prevention |
| Increase Vaccination |
| Acute Care Hospital |
| Staff COVID-19 Vaccination |
| 180 - COVID–19 Vaccination Coverage among Healthcare Personnel - Active (00180-01-C-ASCQR) |
| No |
| TBD |
| TBD |
| Prevention |
| Increase Vaccination |
| Acute Care Hospital |
| Staff Influenza Vaccination |
| 390 - Influenza Vaccination Coverage among Healthcare Personnel - Active (00390-01-C-HIQR) |
| No |
| TBD |
| TBD |
| Prevention |
| Increase Vaccination |
| Nursing Home |
| Staff COVID-19 Vaccination |
| 180 - COVID–19 Vaccination Coverage among Healthcare Personnel |
| No |
| No |
| TBD |
| Prevention |
| Increase Vaccination |
| Nursing Home |
| Resident COVID-19 Vaccination |
| NHSN Measure |
| No |
| No |
| TBD |
| Prevention |
| Increase Vaccination |
| Nursing Home |
| Resident Influenza Vaccination |
| Not applicable |
| No |
| No |
| TBD |
| Prevention |
| Increase Vaccination |
| Nursing Home |
| Resident Pneumococcal Vaccination |
| 519 - Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (LS) - Active (00519-02-C-NHQI) |
| No |
| No |
| TBD |
| Prevention |
| Increase Vaccination |
| Outpatient Clinician |
| Adult Immunization Status: Up-to-date routine vaccinations for influenza, Td, Tdap, zoster, pneumococcal |
| 110 - Influenza; 111 - Pneumococcal |
| Yes |
| Reliability only |
| TBD |
| Prevention |
| Prevent or manage diabetes, hypertension, chronic kidney disease |
| Outpatient Clinician |
| Preventative Care and Screening: BMI Screening and Follow-up |
594 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan - Active (00594-02-E-MIPS)
| Prevention |
| Prevent or manage diabetes, hypertension, chronic kidney disease |
| Outpatient Clinician |
| Diabetes: HbA1C Poor Control (>9%) |
| 204 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) - Active (00204-03-E-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Prevention |
| Prevent or manage diabetes, hypertension, chronic kidney disease |
| Outpatient Clinician |
| Hypertension: Controlling HBP |
| 167 - Controlling High Blood Pressure - Active (00167-04-E-MIPS) |
| Yes |
| Reliability only |
| TBD |
| Prevention |
| Prevent or manage diabetes, hypertension, chronic kidney disease |
| Outpatient Clinician |
| Kidney Health Evaluation |
| 989 - Kidney Health Evaluation for Patients with Diabetes (KED) - Active (00989-02-C-MQRS) |
| Yes |
| Reliability only |
| TBD |
| Prevention |
| Prevent or manage diabetes, hypertension, chronic kidney disease |
| Outpatient Clinician |
| Use of Home Dialysis upon Initiation of Dialysis |
| Not applicable |
| No |
| No |
| TBD |