Quality Measures

Quality measures are tools that help measure and track the quality of health care services provided by health care professionals, clinics and hospitals within the PQA health care network. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care.

Tracking and reporting quality measures helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care.

Our quality measures and their descriptions are listed below.

PQRS = Physician Quality Reporting System (www.cms.gov/PQRS)


PQRSQuality MeasureSpecialtiesDetails
1 Diabetic Blood Sugar Control Allergy and Immunology, Family Medicine, Internal Medicine, Pharmacist, Wound Care Details
5 ACE/ARB for LVSD Family Practice, Internal Medicine, Cardiology Details
6 MI Patients given ASA on ED Arrival Emergency Details
12 Glaucoma optic nerve eval Ophthalmology Details
14 Macular Degeneration dilated exam Ophthalmology Details
19 Diabetic retinopathy communication with PCP Ophthalmology Details
21 Selection of prophylactic antibiotics General Surgery, Cardiovascular Surgery, ENT, Neurosurgery, Obstetrics/Gynecology, Orthopedics, Urology, Vascular Surgery, Podiatry Details
32 Stroke: DC on antithrombotic Neurology Details
39 Osteoporosis screening over age 65 Orthopedics, Rheumatology Details
44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Anesthesiology Details
47 Advance Care Plan Home Health, Hospice Details
53 Asthma: use of controller med for persistent Pulmonology, Allergy & Immunology, Family Practice, Internal Medicine, Pediatrics Details
54 ECG for chest pain Emergency Details
65 No antibiotic for children with URI Family Practice, Pediatrics Details
68 Myelodysplastic Syndrome iron stores eval Oncology Details
69 Multiple Myeloma bisphosphonate use Oncology Details
70 CLL baseline flow cytometry Oncology Details
71 Hormone therapy for estrogen recept+ Breast CA Oncology Details
72 Colon Cancer AJCC Stage III Chemo Oncology Details
76 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol Anesthesiology, Critical Care Medicine, Radiology Details
93 Appropriate use of antibiotics for Otitis Media Pediatrics Details
99 Breast cancer resection reporting for staging Pathology Details
100 Colon cancer resection reporting for staging Pathology Details
109 Osteoarthritis pain and function eval Orthopedics, Rheumatology Details
110 Influenza vaccination Family Practice, Internal Medicine, Pediatrics, Emergency, ENT, Infectious Disease, Obstetrics/Gynecology, Pulmonology, Allergy & Immunology, Skilled Nursing/Transitional Care Details
111 Pneumococcal vaccination Family Practice, Internal Medicine, Pediatrics, Emergency, ENT, Infectious Disease, Pulmonology, Allergy & Immunology, Critical Care Medicine, Skilled Nursing/Transitional Care Details
112 Breast Cancer screening Family Practice, Internal Medicine, Obstetrics/Gynecology Details
113 Colon Cancer screening Family Practice, Internal Medicine, Gastroenterology Details
117 Diabetes: Eye Exam Home Health Details
118 CAD ACEI or ARB Family Practice, Internal Medicine, Cardiology Details
119 Diabetic treatment for neuropathy Nephrology, Critical Care Medicine, Home Health Details
121 Adult Kidney Disease: Laboratory Testing (Lipid Profile) Nephrology Details
122 BP control in CKD patients Nephrology Details
127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Podiatry Details
128 BMI screening and follow up (peds and adult) Family Practice, Internal Medicine, Pediatrics, Cardiology, Dermatology, Gastroenterology, Infectious Disease, Obstetrics/Gynecology, Endocrinology, Podiatry, Psychiatry, Psychology/Counseling, Wound Care, Sports/Physical Medicine, Physical/Occupational Therapy Details
130 Documentation of medications in record Endocrinology, Infectious Disease, Nephrology, Psychiatry, Psychology/Counseling, Cardiovascular Surgery, Dermatology, Allergy & Immunology, Anesthesiology, Critical Care Medicine, Gastroenterology, General Surgery, Home Health, Hospice, Infectious Disease, Neurology, Neurosurgery, Ophthalmology, Podiatry, Rheumatology, Speech Therapy, Urology, Vascular Surgery, Wound Care, Sports/Physical Medicine, Physical/Occupational Therapy, Chiropractic Details
131 Pain Assessment & Follow-up Chiropractic, Hospice, Sports/Physical Medicine, Physical/Occupational Therapy, Speech Therapy, Wound Care, Neurology Details
134 Screening for depression Psychiatry, Psychology/Counseling, Hospice, Skilled Nursing/Transitional Care, Speech Therapy Details
137 Melanoma recall system Dermatology Details
138 Melanoma Care Coordination Dermatology Details
145 Fluoroscopy exposure time Radiology Details
154 Falls: Risk Assessment Critical Care Medicine, Home Health, Hospice, Sports/Physical Medicine, Physical/Occupational Therapy, Skilled Nursing/Transitional Care Details
155 Falls: Plan of Care Sports/Physical Medicine, Physical/Occupational Therapy Details
163 Diabetes: Foot Exam Home Health, Podiatry, Skilled Nursing/Transitional Care Details
173 Screening for unhealthy alcohol use Psychiatry, Psychology/Counseling Details
178 Rheumatoid arthritis functional status assess Rheumatology Details
182 Functional Outcome Assessment Chiropractic Details
185 Adenomatous polyp surveillance Gastroenterology Details
193 Perioperative Temperature Management Anesthesiology Details
195 Carotid stenosis quantification Radiology Details
225 Mammogram reminder system Radiology Details
226 Tobacco use screening and counseling Family Practice, Internal Medicine, Cardiology, Cardiovascular Surgery, Dermatology, Emergency, ENT, Gastroenterology, Infectious Disease, Obstetrics/Gynecology, Pulmonology, Pediatrics, Chiropractic, Endocrinology, General Surgery, Home Health, Nephrology, Neurology, Neurosurgery, Ophthalmology, Orthopedics, Psychiatry, Psychology/Counseling, Rheumatology, Speech Therapy, Urology, Vascular Surgery, Wound Care Details
236 BP Control <140/90 or 140/80 Family Practice, Internal Medicine, Cardiology, Cardiovascular Surgery, Nephrology, Neurology, Endocrinology, Sports/Physical Medicine Details
239 PCP visit with BMI, nutrition and physical actiuvity counseling Family Practice, Internal Medicine, Pediatrics Details
240 Childhood Immunization Status Family Practice, Pediatrics Details
250 Prostate cancer resection reporting for staging Pathology Details
251 Breast cancer HER2 receptor testing Pathology Details
265 Biopsy Follow-Up Radiology Details
309 Cervical cancer screening Family Practice, Obstetrics/Gynecology, Internal Medicine Details
311 Use of Appropriate Medications for Asthma Allergy & Immunology Details
317 Blood Pressure Screening Anesthesiology, Chiropractic, Endocrinology, General Surgery, Home Health, Neurology, Neurosurgery, Ophthalmology, Pulmonology, Rheumatology, Speech Therapy, Urology, Vascular Surgery Details
357 Percentage of patients aged 18 years and older who had a surgical site infection (SSI) General Surgery, Cardiovascular Surgery, ENT, Neurosurgery, Obstetrics/Gynecology, Orthopedics, Urology, Vascular Surgery Details
397 Pathology reports for primary malignant cutaneous melanoma Pathology Details