Composite Measure

The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

Composite 1: Patient-Centered Access
Composite 2: Team-Based Care
Composite 3: Population Health Management
Composite 4: Care Management and Support
Composite 5: Care Coordination and Care Transitions

A composite measure of in-hospital mortality indicators for selected conditions.

The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:
• HbA1c less than 8.0 mg/dL
• Blood Pressure less than 140/90 mmHg
• On a statin medication, unless allowed contraindications or exceptions are present
• Non-tobacco user
• Patient with ischemic vascular disease is on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present

The proportion of acute MI patients >= 18 years of age that receive "perfect care" based upon their eligibility for each performance measures

The PSI 90 composite measure summarizes patient safety across multiple indicators for the CMS Medicare fee-for-service population.

Pediatric Patient Safety for Selected Indicators (PDI 19) is a weighted average of the observed-to-expected ratios for the following component indicators: PDI 01 Accidental Puncture or Laceration Rate, PDI 02 Pressure Ulcer Rate, PDI 05 Iatrogenic Pneumothorax Rate, PDI 10 Postoperative Sepsis Rate, PDI 11 Postoperative Wound Dehiscence Rate, and PDI 12 Central Venous Catheter-Related Blood Stream Infection Rate.

Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge

Percentage of deliveries in the measurement period in which women received influenza and tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccinations.

The Promoting Healthy Development Survey (PHDS) is a 43-item parent survey that can be used by health care providers, health systems, Medicaid agencies, and other stakeholders to measure and improve the quality of preventive and developmental care for children ages 0-48 months. The survey is designed to measure parent’s experience with care and the extent to which they received preventative and developmental services in accordance with nationally recommended guidelines put forth by the American Academy of Pediatrics and Bright Futures practice guidelines (3rd edition).1

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types: