Glossary

Allowance for Patient or Population Factors The type of analytic considerations made for the measure based on patient factors or characteristics (e.g., stratification by subgroups, case-mix adjustment, risk adjustment, using paired data at the patient level). Analysis by high-risk subgroup (stratification by vulnerable populations)
A systematic examination and evaluation of measurement data by separating out populations with different vulnerabilities (e.g., children, frail elderly, the homeless, the medically uninsured). In this way, comparisons are made within groups with similar risks for receiving poor care. Analysis by subgroup (stratification by individual factors, geographic factors, etc.)
A systematic examination of measurement data by separating out populations with different characteristics relevant to the receipt of health care. Case-mix adjustment
A tool that adjusts for either sociodemographic differences or differences in the health condition, or clinical characteristics, and service needs of individuals. It is used in reporting on health care performance to accommodate the fact that it is more difficult or complex to provide care for some types of individuals. Paired data at patient level
A method of collecting data from each individual in the denominator at two points in time to observe changes in health state that may be attributed to health care. Observation of any change at the time of the second observation adjusts for each individual's base line health state. Risk adjustment devised specifically for this measure/condition
A statistical process used to identify and adjust for variation in patient health outcomes that stem from differences in patient characteristics such as severity of illness and presence of co-morbidities. Risk factors present at the receipt of health care may cause individuals to experience different outcomes regardless of the quality of care provided. Comparing patient health outcomes across organizations without appropriate risk adjustment can be misleading. Risk adjustment is best developed when it is purposefully designed for the condition under study. (1) Risk adjustment method widely or commercially available
Risk adjustments that are designed for widespread application in many different types of analyses and not specifically designed for any one measurement.

Case Finding Period The time period that is searched to determine if a case/event is potentially eligible for the denominator.

Clinical Practice Guideline Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. (2)

Current Use Identifies the types of initiatives or activities in which the measure is implemented at the present time. Accreditation
A process whereby a professional association or nongovernmental agency grants recognition to a school or health care institution for demonstrated ability to meet predetermined criteria for established standards. (3) Collaborative inter-organizational quality improvement
Initiatives in which multiple separate health care entities participate and work together to analyze performance and make systematic efforts to improve it. (4) Decision-making by businesses about health plan purchasing
Example: A business or business coalition may use publicly reported or privately purchased performance measure data as a criterion for determining which health plans to purchase and offer to their employees. Decision-making by consumers about health plan/provider choice
Example: Employers or consumer groups may make performance measure data available to individuals in order to enable them to select health plans or providers that are deemed to be higher quality or higher "value." Decision-making by health plans about provider contracting
Example: Health plans may use performance measure data to determine which providers they will include in their network or to place providers into "tiers" based on their perceived level of quality or "value." Decision-making by managers about resource allocation
Example: Managers of health care organizations or employers that provide health care may use performance measure data to determine priorities for purchasing and investment. External oversight/Department of Defense/TRICARE
Monitoring by the Department of Defense (DOD), or the TRICARE federal health plan for active duty military personnel, of health care organizations that operate independently of DOD or TRICARE. External oversight/Health plans
Monitoring by health plans of health care organizations that operate independently of the plans. External oversight/Indian Health Service
Monitoring by the Indian Health Service (IHS) of health care organizations that operate independently of IHS. External oversight/Maternal and Child Health Bureau
Monitoring by the Maternal and Child Health Bureau (MCHB) of health care organizations that operate independently of MCHB. External oversight/Medicaid
Monitoring by Medicaid of health care organizations that operate independently of Medicaid. External oversight/Medicare
Monitoring by Medicare of health care organizations that operate independently of Medicare. External oversight/Other national programs
Monitoring by national programs (other than DOD, IHS, MCHB, Medicaid, Medicare, or the Veterans Health Administration) of health care organizations that operate independently of the monitoring entity. External oversight/Prison health care systems
Monitoring by prison health care systems of health care organizations that operate independently of the monitoring entity. External oversight/Regional, county, or city agencies
Monitoring by the regional, county, or city agencies of health care organizations that operate independently of the monitoring entity. External oversight/State government program
Monitoring by state government programs of health care organizations that operate independently of the monitoring entity. External oversight/Veterans Health Administration
Monitoring by the Veterans Health Administration (VA) of health care organizations that operate independently of the VA. Internal quality improvement
A formal approach to the analysis of performance and systematic efforts to improve it within an organization. (4) Monitoring and planning
Systematic, ongoing observation and tracking, and formulation of a program for a course of action. (5, 6) Monitoring health state(s)
Systematic, ongoing observation and tracking of clinically diagnosed conditions. (6) National health care facility monitoring
Systematic, ongoing observation and tracking of health care facilities at the national level. (6) National health policymaking
Formulation of a plan of action for health or health care at the national level. National reporting
Reporting by a governmental agency using population-based data reflecting the overall health of a nation.

Example: Measures included in the National Healthcare Quality Report (NHQR).

Pay-for-performance
Health care payment models that offer financial rewards to providers who achieve or exceed specified quality benchmarks. (7) Pay-for-reporting
A mechanism through which health care providers receive payments for providing data derived from measures of quality or related performance. Population health improvement
Enhancement of the health outcomes of a group of individuals, including the distribution of such outcomes within the group. (8) Professional certification
A designation earned by a person to assure qualification to perform a job or task, often from an oversight professional body acting to safeguard the public interest. (9) Public reporting
Refers to any effort to provide a public audience with information that allows rating or comparison of providers according to standards of quality or resource use.

Example: Measures included in the Hospital Compare.

Quality of care research
Systematic examination of how people get access to health care, how much care costs, and what happens to patients as a result of this care, which is intended to identify the most effective ways to organize, manage, finance, and deliver high quality care; reduce medical errors; and improve patient safety. (10) Regional, county, or city health policymaking
Formulation of a plan of action for health or health care at the regional, county, or city level. State/Provincial health policymaking
Formulation of a plan of action for health or health care at the state or provincial level.

Data Source Identifies the data source(s) necessary to implement the measure. Administrative clinical data
Data such as enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on, gathered from billing codes or other coding systems. This refers to information that is collected, processed, and stored in automated information systems. (11) Administrative management data
Data that describe attributes of delivery organizations, staff, equipment, non-clinical operations, and financing. Clinical training documentation
The recording of the details of educational and related activities intended to augment the skills and knowledge of clinical personnel. Documentation of organizational self-assessment
An organization's record keeping of its identifiable strengths and noticeable gaps in agency performance. The assessment serves to provide agencies with the means to evaluate and understand their own systems and program operations in order to strengthen the services delivered to the community and gain accreditation. (12) Electronic health/medical record
In health informatics, an electronic medical record (EMR) is considered to be one of several types of electronic health records (EHRs), but EMR and EHR are also used interchangeably. EHRs are sometimes defined as including other systems that keep track of medical information, such as practice management software that facilitates the day-to-day operations of a medical practice. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payers, perform billing tasks, and generate reports. (1) External audit
A review of a health care organization by a separate organizational entity that examines structures in the health care setting (e.g., facilities, staffing, or the availability of drugs and equipment) or the management of particular clinical or administrative processes. (13) Health professional survey
An investigation aimed at gathering information from health professionals to search and disseminate information relating to their professions. (14)

Example: The World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) developed the Global Health Professional Survey (GHPS) in 2004 to collect data on tobacco use and cessation counseling among health professional students. (15)

Imaging data
Data derived from the use of radiographic, sonographic, and other technologies. (16)

Example: PET, CT, MRI, X-ray.

Inspections/Site visits
A formal visit to a hospital or heath care facility by representatives from an accrediting organization (e.g., The Joint Commission [TJC], Centers for Medicare & Medicaid Services [CMS]) to assess the quality of care provided in the institution, as reflected by the facility's adherence to guidelines for providing such care. (17) Laboratory data
Data collected from a site equipped for experimentation, observation, testing and analysis, or practice in a field of study. (18) In regards to clinical practice, laboratory data may provide information on diagnosis, prognosis, prevention, or treatment of disease based on close examination of the human body. (19) National public health data
Public health data include national health status (gathered through birth and death certificates, hospital discharge diagnoses, other epidemiologic sources), communicable disease (food/water/air/waste/vector borne), environmental health risks, presence of and use of health care facilities and providers, preventive services, and other information identified by the nation as helpful for planning. (20)

Example: Data available from the National Center for Health Statistics, such as National Health Interview Survey (NHIS) or National Health and Nutrition Examination Survey.

Organizational policies and procedures
Refers to the principles and methods, whether formalized, authorized, or documented, that enable people affiliated with an organization to perform in a predictable, repeatable, and consistent way. (21) Paper medical record
A collection of hard-copy documents compiled and maintained by health care professionals in the course of providing care to patients. Patient/Individual survey
An instrument that assesses patients' perspectives on any of the following: their health and the care they receive, including the level of patients' satisfaction, or patients' understanding of their health status. Pharmacy data
A database that provides information on prescription and/or dispensing of drug and non-drug products that may be obtained from a pharmacy (retail or health care institution-based). The information provided may include clinical attributes such as the product's ingredients (e.g., ampicillin), drug classes (e.g., antibiotics, penicillins), strength (e.g., 500mg), and form (e.g., capsule). Non-clinical information provided may include manufacturer (e.g., Merck), packaging (e.g., 500 per bottle), and price (e.g., $2 per 500). (22) Provider characteristics
Specific descriptive information about the clinician provider or the facility caring for the patient.

Example: Whether a provider is board certified. Whether a hospital uses an electronic health record. (23)

Region, county, or city public health data
Public health data include community health status on a region/county/city level (gathered through birth and death certificates, hospital discharge diagnoses, local surveys, other epidemiologic sources), communicable disease (food/water/air/waste/vector borne), environmental health risks, presence of and use of health care facilities and providers, preventive services, and other information identified by the local community as helpful for planning. (20)

Example: The City of Baltimore Department of Public Health maintains a variety of health data files. (24)

Registry data
Data derived from an organized system for the collection, storage, retrieval, analysis, and dissemination of information on individual persons who have a clinical condition that predisposes them to the occurrence of a health-related event, or prior exposure to substances (or circumstances) known or suspected to cause adverse health effects. (25)

Example: Cystic Fibrosis Foundation Patient Registry (see: http://www.cff.org/LivingWithCF/CareCenterNetwork/PatientRegistry/)

Special or unique data
A data source that is unique to an organization.

Example: Patient safety organizations (PSOs) may hold protected data on root cause analyses that can only be accessed with special permission.

State/Province public health data
Public health data include community health status on a state/province level (gathered through birth and death certificates, hospital discharge diagnoses, statewide and local surveys, other epidemiologic sources), communicable disease (food/water/air/waste/vector borne), environmental health risks, presence of and use of health care facilities and providers, preventive services, and other information identified by the community as helpful for planning. (20)

Example: Behavioral Risk Factor Surveillance System is the world's largest, on-going telephone health survey system, tracking health conditions and risk behaviors in the United States yearly since 1984. Currently, data are collected monthly in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. (26)

Denominator The lower part of the fraction used to calculate a rate or ratio defining the total population of interest for a quality measure. (1)

Denominator (Index) Event or Characteristic The event or characteristic that defines eligibility for inclusion in the denominator group. Clinical Condition
A disease, illness, injury, or health risk state. (27, 28)

Example: Diabetes; hip fracture: HIV status; pregnancy; smoking status.

Diagnostic Evaluation
An assessment of symptoms and/or functional impairment intended to identify the presence or absence of a clinical condition.

Example: Depression screening; colorectal cancer screening.

Encounter
An interaction between a patient and a practitioner in an ambulatory setting for the purpose of assessing and treating the patient.

Example: Clinic visit; emergency department (ED) visit.

Geographic Location
A place within a specified boundary.

Example: Country; state; county; region

Health Care/Public Health Organization Characteristic
An attribute of an institution responsible for delivery of health care or for a public health program.

Example: Institution type -- hospital, long-term care facility, primary care practice.

Health Professional Characteristic
An attribute of an individual who provides health care or a public health intervention, or is an employee of an organization/facility that delivers health care or a public health program.

Example: Clinician type -- primary care physician, surgeon, advanced practice nurse.

Institutionalization
The care delivered in a hospital, rehabilitation hospital, or nursing home from admission to discharge, regardless of length of stay (e.g., the proportion of patients in a psychiatric facility who are physically restrained during their hospitalization).

Example: Admission; nursing home stay.

Patient/Individual (Consumer) Characteristic
An attribute of an individual recipient (or potential recipient) of health services, or of a member of a population targeted by a public health program.

Example: Age; gender.

Therapeutic Intervention
An activity or set of activities carried out to improve or maintain the health of a person. (29)

Example: Medication, surgery, physical therapy.

Denominator Sampling Frame The list of all cases/events potentially eligible for inclusion in the denominator, from which a more restrictive sample of cases is sometimes selected. Clinical information
Information about a potential subject of health care or a public health initiative relevant to the individual's health or treatment or to the public's health.

Example: Information identifying patients with asthma who had an emergency room visit or a hospitalization within a given time frame.

Enrollees or beneficiaries
Enrollees are persons who have registered with a managed care plan to be eligible to receive health care. Beneficiaries are persons eligible for coverage of health care services by either a public or private health insurance program. Equipment/Supplies
Materials used in providing health care or a public health intervention. Geographically defined
Persons located within a specified boundary.

Example: Country; state; county; region

Health care or public health organization
An organization responsible for delivery of health care or for a public health intervention to a defined population. Organizationally defined (non-health care organizations)
Refers to non-health care organizations that comprise part of the sampling frame for a quality measure.

Example: Schools or prisons.

Patients associated with provider
Persons defined as within the sampling frame for a quality measure based on their clinical relationship with a provider.

Example: Clinician or facility delivering health care.

Professionals/Staff
Individuals who provide health care or a public health intervention, or employees of an organization/facility that delivers health care or a public health intervention.

Denominator Time Window The time period in which occurrences identified as potentially eligible for inclusion in the denominator are reviewed to determine whether or not they are finally included. Time window brackets index event
The denominator time window covers a time period beginning before and following after the index date.

Example: Prenatal care patients who were continuously enrolled at least 43 days prior to delivery through 56 days after delivery, where delivery is the index event.

Time window follows index event
The denominator time window covers a period following immediately after the index date.

Example: Patients discharged post myocardial infarction (MI) who survived for six months where hospital discharge following MI is the index event.

Time window precedes index event
The denominator time window covers a period before and up to the index date.

Example: Patients with newly diagnosed cases of otitis media where the index event is the new diagnosis, with a new diagnosis defined by checking that care for otitis media was not given 3 months prior to the index event.

Disaggregation The separation of data that have been previously grouped for analytic purposes.

Example: Consumer experience survey data on a physician organization may be disaggregated for analysis at the level of individual physicians.

Domains In NQMC, a 'domain' is a category of measures that are related to one another because they address a similar aspect of the quality or performance of health systems. Using Donabedian's triad of structure, process, and outcome as a conceptual foundation, the NQMC Domain Framework defines 11 domains of health care delivery measures and 13 domains of population health measures.

For a graphical representation of the domains represented in NQMC, refer to the NQMC Domain Framework.

Health Care Delivery Measure Domains: Measures of care delivered to individuals and populations defined by their relationship to clinicians, clinical delivery teams, delivery organizations, or health insurance plans. Denominators for these measures are defined by some form of affiliation with a clinical care delivery organization, e.g. recipients of health care, health plan enrollees, clinical episodes, clinicians, or clinical delivery organizations.

Clinical Quality Measures: Measures used to assess the performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees, which are supported by evidence demonstrating that they indicate better or worse care.

Process: A process of care is a health care-related activity performed for, on behalf of, or by a patient.

Example: The percentage of patients with chronic stable coronary artery disease (CAD) who were prescribed lipid-lowering therapy.

Access: Access to care is the attainment of timely and appropriate health care by patients or enrollees of a health care organization or clinician.

Example: The percentage of members 12 months to 19 years of age who had a visit with a primary care practitioner in the past year (based on evidence that annual visits lead to better health outcomes for children and youth).

Outcome: An outcome of care is a health state of a patient resulting from health care.

Example: The risk-adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges.

Structure: Structure of care is a feature of a health care organization or clinician related to the capacity to provide high quality health care.

Example: Does the health care organization use Computerized Physician Order Entry (CPOE) (based on evidence that the presence of CPOE is associated with better performance and lower rates of medication error)?

Patient Experience: Experience of care is a patient's or enrollee's report of observations of and participation in health care, or assessment of any resulting change in their health.

Example: The percentage of adult inpatients that reported how often their doctors communicated well.

Related Health Care Delivery Measures: Measures used to assess the non-quality aspects of performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees. These measures are not supported by evidence demonstrating that they indicate better or worse care.

User-Enrollee Health State: A user-enrollee health state is the health status of a group of persons identified by enrollment in a health plan or through use of clinical services.

Example: Prevalence of diabetes among health plan enrollees (inclusion in the denominator is based on membership in a particular health plan; however, the measured health state is not a result of that membership).

Management: Management of care is a feature of a health care organization related to the administration and oversight of facilities, organizations, teams, professionals, and staff that deliver health services to individuals or populations.

Example: Whether a practice has a policy to ensure the prevention of fraud and has defined levels of financial responsibility and accountability for staff undertaking financial transactions.

Use of Services: Use of services is the provision of a service to, on behalf of, or by a group of persons identified by enrollment in a health plan or through use of clinical services.

Example: The percentage of patients in a health plan with an inpatient admission in the prior twelve months.

Cost: Costs of care are the monetary or resource units expended by a health care organization or clinician to deliver health care to individuals or populations. Cost measures are computed from data in monetary or resource units.

Example: Hospital net inpatient revenue per discharge.

Clinical Efficiency Measures: Measures that may be used to assess efficiency directly (e.g., by comparing a measure of quality to a measure of resource use) or indirectly (e.g., by measuring the frequency with which health care processes are implemented that have been demonstrated by evidence to be efficient).

Efficiency: Efficiency of care is a measure of the relationship between a specific level of quality of health care provided and the resources used to provide that care.

Example: Percentage of gastric ulcers treated with omeprazole (based on evidence that this is lower cost and at least equally effective as surgery).

Population Health Measure Domains: Measures that address health issues of individuals or populations defined by residence in a geographic area or a relationship to organizations that are not primarily organized to deliver or pay for health care services (such as schools or prisons). The responsibility for "performance" typically falls to public officials, public health agencies, or organizations that are not primarily deliverers of care.

Population Health Quality Measures: Measures applied to groups of persons identified by geographic location, organizational affiliation or non-clinical characteristics, in order to assess public health programs, community influences on health, or population-level health characteristics that may not be directly attributable to the care delivery system. These measures are supported by evidence demonstrating that they indicate better or worse performance of population health activities.

Population Process: A population process of care is a public health-related practice or service performed for, on behalf of, or by a population.

Example: The proportion of adults ages 65 years and older in a county who have received an influenza vaccination in the past year.

Population Access: Population access to care is the timely and appropriate receipt of a public health intervention by a population.

Example: The percentage of smokers in a county who reported that they were able to access a smoking-cessation program.

Population Outcome: A population outcome is a health state of a population resulting from a public health intervention.

Example: The proportion of children with elevated blood lead levels whose homes undergo lead remediation, and whose blood lead levels are subsequently reduced to normal levels.

Population Structure: Population structure of care is a feature of a public health program related to its capacity to provide high quality public health services to a population.

Example: The number of licensed child care facilities and slots in a county.

Population Experience: Population experience is the report of the members of a population concerning observations of and participation in public health programs.

Example: The percentage of smokers in a county reporting that they have seen or heard public service announcements promoting a county health department-sponsored smoking-cessation program.

Related Population Health Measures: Measures applied to groups of persons identified by geographic location, organizational affiliation or non-clinical characteristics, in order to assess non-quality aspects of public health programs, community influences on health, or population-level health characteristics that may not be directly attributable to the care delivery system. These measures are not supported by evidence demonstrating a link to better or worse performance of population health activities.

Population Health State: Population health state is the health status of a population.

Example: The prevalence rate of asthma for a county.

Population Management: Population management is a feature of a public health system that is relevant to the system's administration, oversight, or staff.

Example: Whether a public health department uses competitive bidding to award contracts for social marketing campaigns.

Population Use of Services: Population use of services is the provision of services to, on behalf of, or use by a population.

Example: The percent of assisted-living facility beds that are occupied in a county.

Population Cost: Population costs of care are the monetary or resource units expended to deliver public health interventions to a population. Cost measures are computed from data in monetary or resource units.

Example: The average per beneficiary Medicaid expenditures in a county.

Population Health Knowledge: Population health knowledge is the awareness and understanding of health-related information such as risk factors, prevention strategies, or treatment recommendations.

Example: The mean response score to a set of questions about human immunodeficiency virus (HIV) prevention.

Social Determinants of Health: Social determinants of health are characteristics of a population related to social position or economic status, such as age, gender, or poverty status, that evidence has shown to be related to health states.

Example: The proportion of families living at or below the poverty level.

Environment: Environment represents the conditions outside of the health care delivery system that may influence the health of a population.

Example: The number of days in the past year when the concentration of particulate air pollution in a community exceeds a defined threshold.

Population Efficiency Measures: Measures that may be used to assess efficiency directly (e.g., by comparing a measure of quality to a measure of resource use) or indirectly (e.g., by measuring the frequency with which population health processes are implemented that have been demonstrated by evidence to be efficient).

Population Efficiency: Efficiency of population health is the amount of resources used to attain a specific level of quality on measures related to maintaining or improving the health of a population.

Example: Day case surgery rates, as a percentage of all surgery cases that could be treated in an outpatient setting, in a county (based on evidence that day case surgery is equally or more effective and because day case surgery is presumably less costly).

eMeasure Performance measures that have been specified such that they can be implemented using data directly from electronic health records (EHR) or other electronic data sources, without manual coding or abstraction from paper records.

Endorsement Consensus-based process through which performance measures are reviewed and assessed against threshold criteria, such as validity, replicability, or impact.

Evidence-based Practice A health care practice that has been demonstrated by research results to have a positive effect on desirable health outcomes when applied under appropriate circumstances.

Exclusion Criteria Specifications of those characteristics that would cause groups of individuals to be removed from the numerator and/or denominator of a measure although they experience the denominator index event. For instance, the denominator index event may specify a discharge diagnosis, but patients with certain co-morbidities may be excluded.

Exclusions/Exceptions Characteristics defined during the delivery of care that would mean that care specified in the numerator was contraindicated, refused by the patient, or not possible for some other compelling and particular circumstance of this case.

Health State The type of health state for Outcome, User-enrollee Health State, Population Outcome, and Population Health State measures according to one of the following values: Adverse Health State
A negative health condition resulting from unintended consequences of health care.

Example: The presence of a pressure ulcer developed during an inpatient hospitalization.

Clinically Diagnosed Condition
The presence of a clinically diagnosed condition, determined from medical records, claims data, or as reported by a clinician.

Example: A diagnosis of diabetes by a physician.

Death
The officially certified cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem), and breathing. (30) Functional Status
A measure of an individual's ability to perform normal activities of life.

Example: An improvement in the ability to dress oneself without assistance.

Health Risk State or Behavior
A measure where risk is a factor for a clinically diagnosable condition. This should not be a clinically diagnosed condition itself.

Example: Active tobacco use.

Individually Reported Health State
The presence of a clinically diagnosed condition as reported by the patient.

Example: Self-reported hypertension (i.e., reported on a patient survey and not confirmed with a clinical diagnosis).

Physiologic Health State (Intermediate Outcome)
This refers to a change produced by a health care intervention that leads to a longer term outcome (e.g., a reduction in blood pressure is an intermediate outcome that leads to a reduction in the risk of longer term outcomes such as cardiac infarction or stroke). Proxy for Health State
Utilization of a health care service, or other type of activity, used as an indicator of health status.

Example: Missed school days.

Proxy for Outcome
A process of care used as an indicator of health status (e.g., an admission to a hospital used as an indication of increased severity of illness).

Inclusion Criteria Specifications of the characteristics that define membership in a group. (a) Denominator inclusion criteria define those individuals or events that are included in the denominator of a measure. (b) Numerator inclusion criteria define those individuals or events, already defined as belonging to the denominator, that are also included in the numerator of a measure. (c) NQMC Inclusion Criteria are used to define those among submitted measures that can be included in NQMC.

Institute of Medicine (IOM) A private, nonprofit institution that provides objective, timely, authoritative information and advice concerning health and science policy to government, the corporate sector, the professions, and the public under a congressional charter.

Institute of Medicine (IOM) Care Needs An attribute that classifies the measure into one or more of the following IOM care need classifications where applicable: End of life care
Care related to those not expected to survive more than six months. Getting better
Care related to acute illness or injury. Living with illness
Care related to chronic or recurrent illness. Staying healthy
Care related to healthy populations or the general health needs of non-healthy populations (e.g., health promotion, disease prevention, risk factor assessment, early detection by screening and treatment of pre-symptomatic disease).

Institute of Medicine (IOM) Domains An attribute that classifies the measure into one or more of the following IOM domains where applicable: Effectiveness
Relates to providing care processes and achieving outcomes as supported by scientific evidence. Efficiency
Relates to avoiding waste, including waste of equipment, supplies, ideas, and energy. Equity
Relates to providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Patient centeredness
Relates to meeting patient's needs and preferences and providing education and support. Safety
Relates to actual or potential bodily harm. Timeliness
Relates to obtaining needed care while minimizing delays.

Least Aggregated Level of Services Delivery Addressed The most discrete level of services delivery for which the measure was developed according to one of the following values: Clinical Practice or Public Health Sites
(a) Health care delivered by physicians or other clinicians organized in a legally recognized entity for the provision of health care services, sharing space, equipment, personnel, and records for both patient care and business management and who have a predetermined arrangement for the distribution of income. (b) A public health intervention delivered to a population within geographical region. Individual Clinicians or Public Health Professionals
Health care delivered by an individual clinician, offering services on a person-to-person basis, as opposed to group or partnership practice. Metropolitan Statistical Areas/Health Services Areas
Metropolitan Statistical Areas (MSAs) are areas designated by the Office of Management and Budget (OMB) that include major cities and the suburban areas surrounding them. (31) Multisite Health Care or Public Health Organizations
Health care delivered by a facility that is part of a larger organization that has multiple sites across a given state, region, or nation, includes integrated delivery systems. National
Health care delivered across a single national entity (e.g., United States). Regional, County, or City
Health care delivered across one or more regions, counties, or cities. Single Health Care Delivery or Public Health Organizations
Health care delivered by a single facility. State/Provincial
Health care delivered across one or more states/provinces.

Measure-related Terms Several key measure-related terms underpin NQMC and include the following: Clinical
Relating to patients or health care. Clinical Quality
The degree of accomplishment of desired health objectives by a clinician or health care organization. Clinical Quality Measure
A mechanism to assess the degree to which a provider effectively and safely delivers clinical services that are appropriate for the patient in the optimal time period. Composite Measure
A composite measure summarizes the answers to two or more related measures or survey questions (or "items"). Composites can represent concepts that are too complex to be measured with a single item and can thus provide a bigger picture. Using composite measures helps users evaluate the information quickly and easily by summarizing several pieces of information so that users do not get bogged down in details. However, identical scores for the same composite may conceal important differences in the underlying measures; it is therefore desirable to examine the results of the underlying measures as well as the composite. (32) Criterion of Quality
A principle or standard that determines whether a higher or lower score for a measure indicates better care. That is, if two results derived using the same measure differ, then the measure's supporting evidence must indicate whether the higher of the two results represents better or worse quality than the lower result. The type of evidence on which this criterion is based varies by domain. Health
A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. (33) Health Care
The prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered health care providers. Health Care Delivery
The provision of goods and services for the prevention, treatment, and management of illness and the preservation of mental and physical well-being by health care providers. Measure
A mechanism to assign a quantity to an attribute to enable comparisons among entities or over time. Patient
A person receiving care or treatment for their health. In NQMC the phrase "user of care" is synonymous with the word "patient". Some measures in NQMC relate to a population or group of persons including users and nonusers of care. Population
A group of persons identified by geographic location, organizational affiliation, or non-clinical characteristics. Population Health
The health states of a group of individuals, including the distribution of such states within the group. There are multiple determinants of such health states, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior. (34) Population Health Quality
The degree of accomplishment of desired population health objectives by a public health practitioner or organization or by the health system serving a geographically or otherwise non-clinically-identified group of people. Population Health Quality Measure
A mechanism to assess the degree to which public health providers or the health system serving a population effectively and safely delivers health services that are appropriate for the population in the optimal time period. Quality Measure
A mechanism to assign a quantity to quality of care by comparison to a criterion. Quality of Care
The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (35)

Measurement Setting The settings for which the measure was developed according to one or more of the following values: Ambulatory/Office-based Care
Health care services provided to patients on an ambulatory basis rather than by admission to a hospital or other health care facility. The services may be provided by a hospital augmenting its inpatient services or may be provided at a free-standing facility. Ancillary Services
Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care. Behavioral Health Care
Health care services organized to provide mental health care, which may include diagnostic, therapeutic, and preventive mental health services; therapy and/or rehabilitation for substance-dependent individuals; and the use of community resources, individual case work, or group work to promote the adaptive capacities of individuals in relation to their social and economic environments. Community Health Care
Diagnostic, therapeutic, and preventive health care services provided for individuals or families in the community for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability. Community health care takes a public health perspective of addressing the health of all residents in a community and undertaking health education and other public health measures as well as delivery of personal health care. Classic examples of community health care are the federally funded community health centers, most of which are in towns and cities. Emergency Medical Services
Services specifically designed, staffed, and equipped for the emergency care of patients. Home Care
Community health and nursing services providing coordinated multiple service home care to the patient. It includes home-offered services provided by visiting nurses, home health agencies, hospitals, or organized community groups using professional staff for care delivery. Hospices
Facilities or services, that are specifically devoted to providing palliative and supportive care to the patient with a terminal illness and to the patient's family. Hospitals
Includes all hospital facilities such as community hospitals, general hospitals, group practice hospitals, private hospitals, public hospitals, satellite hospitals, rural hospitals, specialty hospitals, teaching hospitals, and urban hospitals. Long-term Care Facilities
Facilities that provide rehabilitative, restorative, and/or ongoing skilled nursing care to patients or residents in need of daily nursing supervision, limited medical care, and/or assistance with activities of daily living. Includes nursing homes, assisted living facilities, inpatient behavioral health facilities, and long-term chronic care hospitals. Managed Care Plans
Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including economic incentives for physicians and patients to select less costly forms of care, programs for reviewing the medical necessity of specific services, increased beneficiary cost sharing, controls on inpatient admissions and lengths of stay, the establishment of cost-sharing incentives for outpatient surgery, selective contracting with health care providers, and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as health maintenance organizations (HMO), independent practice associations (IPA), and preferred provider organizations (PPO), etc. National Public Health Programs
An officially authorized entity concerned with the prevention and control of disease and disability and the promotion of physical and mental health of the population on the national level. (20) Regional, County, or City Public Health Programs
An officially authorized entity concerned with the prevention and control of disease and disability and the promotion of physical and mental health of the population on the regional, county, or city level. (20) Rehabilitation Centers
Facilities/programs that provide interventions and support services intended for rehabilitating individuals with mental illnesses or physical disabilities. Residential Care Facilities
Facilities that provide supervision and assistance in activities of daily living with medical and nursing services when required, generally for those not needing hospital services but still in need of medical assistance. They are usually established as planned, single housekeeping units in residential dwellings that provide care and supervision for small groups of residents, who, although unrelated, live together as a family. Includes group homes, halfway houses, and orphanages. Rural Health Care
Rural health care generally refers to health care services provided to patients who live in rural areas. The services include the promotion of health and the delivery of health care. Some measures specifically address the challenges of delivering quality of care in the special circumstances of rural settings where travel distances are long and public transportation is virtually non-existent. State/Provincial Public Health Programs
An officially authorized entity concerned with the prevention and control of disease and disability and the promotion of physical and mental health of the population on the state level. (20) Substance Use Treatment Programs/Centers
Facilities/programs providing therapy and/or rehabilitation for substance-dependent individuals. Includes inpatient programs and outpatient programs (e.g., methadone distribution centers).

Numerator The upper part of the fraction used to calculate a rate or ratio defining the subset of the population of interest that meets a quality measure's criterion of quality.

Numerator Search Strategy Identifies the type of situation that isolates cases for inclusion in the numerator. Encounter
A specific interaction between a patient and a practitioner in an ambulatory setting for the purpose of assessing and treating the patient.

Example: First visit in a sampling period; primary care visit; emergency department (ED) visit.

Episode of care
The course of health care for an illness or a condition as observed in the chosen data source.

Example: The percentage of patients with a primary diagnosis of schizophrenia who receive an antipsychotic medication between 300 and 600 CPZ equivalents per day during the maintenance phase of the illness.

Fixed time period or point in time
A specified interval of time of any length; it may be as brief as a moment when a particular event occurs, or it may be measured in hours, days, months, or years.

Example: Point at which a patient survey is administered; a birth; a death date; a measurement year (e.g., July 1, 2012 – June 30, 2013).

Institutionalization
The care delivered in a hospital, rehabilitation hospital, or nursing home from admission to discharge, regardless of length of stay.

Example: The proportion of patients in a psychiatric facility who are physically restrained during their hospitalization.

Professionals Involved in the Delivery of Health Services The professional(s) involved in delivering the services addressed by the measure according to one or more of the following attributes: Advanced Practice Nurses
Professionals qualified by education at an accredited school of nursing and licensed by state law to practice nursing. These individuals typically have a master's degree or higher. This category includes nurse administrators, nurse anesthetists, nurse clinicians, nurse practitioners, nurse psychotherapists, and nurse midwives. Allied Health Personnel
Health care workers specially trained and licensed to assist and support the work of health professionals. This group is designed to include most assistive personnel and technicians, such as behavioral therapy assistants, community health aides, dental assistants, dental hygienists, dental technicians, home health aides, medical record administrators, medication administration aides, nurses' aides, psychiatric aides, operating room technicians, pharmacists' aides, and radiology technicians. Chiropractors
Individuals specially trained and licensed to practice chiropractic. Clergy
A qualified and authorized member of a faith community, such as a minister, priest, rabbi, or similar functionary, who is a duly designated representative of a local parish, congregation, or religious organization. (36) Clinical Administrators/Managers
Individuals in an organization that delivers health care who establish, implement, or execute policies or administrative processes. Clinical Laboratory Personnel
Health care professionals, technicians, and assistants staffing a health care facility where specimens are grown, tested, or evaluated and the results of such are recorded. Includes clinical laboratory technician/medical laboratory technician, clinical laboratory scientist/medical technologist, histologic technician/technologist, and pathologists' assistant. Dentists
Individuals licensed to practice dentistry. Dietitians
Individuals with a legally recognized qualification in nutrition and dietetics who apply the science of nutrition to the feeding and education of groups of people and individuals in health and disease. (37) Emergency Medical Technicians/Paramedics
Personnel trained and certified to provide basic emergency care and life support under the supervision of physicians and/or nurses. These services may be carried out at the site of the emergency, in the ambulance, or in a health care institution. Health Educators
Personnel who work to encourage healthy lifestyles, wellness, and self-care practices through informing and educating individuals and communities. Measure is not provider specific
Measure does not apply to specific professionals. Midwife
A person who has successfully completed a prescribed course of studies and has acquired the requisite qualifications to be registered and/or legally licensed to work in partnership with women to give the necessary support, care and advice during pregnancy, labor and the postpartum period, to conduct births and to provide care for the newborn and the infant. (38) Nurses
Professionals qualified by education at an accredited school of nursing and licensed by state law to practice nursing. They provide services to patients requiring assistance in recovering or maintaining their physical or mental health. Occupational Therapists
Persons legally qualified by education and training to engage in the practice of occupational therapy, a field concerned with using craft or work activities in the rehabilitation of patients. Optometrists
Persons who are professionally trained and licensed to examine the eyes for visual defects, diagnose problems or impairments, and prescribe corrective lenses or provide other types of treatment. Pharmacists
Persons legally qualified by education and training to engage in the practice of pharmacy. Physical Therapists
Persons legally qualified by education and training to engage in the practice of physical therapy, a field concerned with the use of special techniques to prevent, correct, and alleviate movement dysfunction of anatomic or physiologic origin. Physician Assistants
Persons academically trained and licensed/credentialed to provide medical care under the supervision of a physician. Physicians
Individuals licensed to practice medicine. This category also includes all physician specialists (e.g., psychiatrists). Podiatrists
Individuals licensed to practice podiatry, the diagnosis and treatment of foot disorders and injuries and anatomic defects of the foot. Psychologists/Non-physician Behavioral Health Clinicians
Persons legally qualified by education and training to practice in the field of mental health (e.g., psychology, counseling, and behavioral health). Public Health Administrators/Managers
Individuals in an organization that acts to promote the public's health who establish, implement, or execute policies or administrative processes. Public Health Professionals
Persons educated in public health or a related discipline who are employed to improve the health of populations. These professionals perform three core functions--assessment, policy development, and assurance of the public's health--as they relate to the prevention and control of disease and disability and the promotion of physical and mental health of populations on an international, national, state, or municipal level. Respiratory Care Practitioners
Individuals trained and certified in the field of respiratory therapy. Social Workers
Individuals trained and certified in the field of social work (e.g., the use of community resources, individual case work, or group work that promotes the adaptive capacities of individuals in relation to their social and economic environments). Speech-language Pathologists
Individuals trained and certified in the field of speech-language pathology, a field dealing with the diagnosis and treatment of speech or language disorders.

Rationale for the Measure The rationale is a brief statement describing the patients and the specific aspect of health care to which the measure applies. The rationale may also include the evidence basis for the measure and an explanation of how to interpret results.

Reliability The extent to which the measure achieves a consistent result (e.g., in terms of internal consistency among items) or the degree to which the measure achieves the same results when applied to the same subjects under the same conditions in a short period of time.

Scoring of the Measure The method used to score the measure according to one of the values below. Scoring applies to the methods that are integral to the measure as designed by its developer for its current use. Other users may choose to analyze and display the results of measurements in additional ways. Composite/Scale
A composite measure is a combination of two or more individual measures into a single measure that results in a single score. The individual component measures are typically highly related to one another, both conceptually and statistically. (39)

A scale is a statistical tool for ordering entities with respect to quantitative attributes or traits, either through the estimation of magnitudes on a continuum or the relative ordering of the entities. (40)

Count
The number of times the unit of analysis for a measure occurs. Dichotomous
A term used to describe a variable or data that can be divided into two categories (e.g., yes or no; present or absent). Frequency Distribution
A display of cases divided into mutually exclusive and contiguous groups along a continuum reflecting gradations of conformance to a quality-related criterion. Mean/Median
Mean: The mathematical average of a set of numbers, calculated by adding two or more scores and dividing the total by the number of scores. (1)

Median: The number separating the higher half of a sample from the lower half. The median of a finite list of numbers can be found by arranging all the observations from lowest value to highest value and picking the middle one. If there is an even number of observations, the median is not unique, so one often takes the mean of the two middle values. (1)

Rate/Proportion
A score derived by dividing the number of cases that meet a criterion for quality (the numerator) by the number of eligible cases within a given time frame (the denominator) where the numerator cases are a subset of the denominator cases (e.g., percentage of eligible women with a mammogram performed in the last year). Ratio
A score that may have a value of zero or greater that is derived by dividing a count of one type of data by a count of another type of data (e.g., the number of patients with central lines who develop infection divided by the number of central line days). Weighted Score
A combination of the values of several items into a single summary value for each case where each item is differentially weighted (i.e., multiplied by an item-specific constant).

Standard of Comparison The type and time frame of the comparison according to one of the following values: External comparison at a point in, or interval of, time
A comparison using the same measure for multiple comparable entities (e.g., non-teaching hospitals, large health plans, or states). External comparison of time trends
A comparison using the same measure for multiple comparable entities tracking change over time. Internal time comparison
A comparison using the same measure in the same organization at two or more points in time to evaluate present or prior performance. Prescriptive standard
A standard set as a goal that ought to be achieved or as a threshold that defines minimum performance. This standard may be derived from studies using different measurement methods.

State of Use Indicates whether the measure is in current use or pilot testing.

Statement of Acceptable Minimum Sample Size An attribute that indicates whether the measure defines a minimum sample size for the denominator. Minimum Recommended Sample Size
The smallest number of entities comprising a sample for a quality measure that is required to achieve an accurate result.

Target Population This refers to the entire group of individuals or objects to which researchers are interested in generalizing the conclusions. Individuals/events in the denominator of a measure are sampled from a target population whose care the measure is intended to represent. (41)

Validity Validity is the ability of a measure to measure what it is intended to measure. Validity is itself measured by the degree to which it lacks both random and systematic error.

Vulnerable Populations Groups of persons who may be compromised in their ability to give informed consent, who are frequently subjected to coercion in their decision making, or whose range of options is severely limited, making them vulnerable to health care quality problems. Children
All infants, children, and adolescents (i.e., all individuals who have not reached the legal age for consent). Disabled
Persons with physical or mental disabilities that affect or limit their activities of daily living and that may require special accommodations. These include cognitively disabled, communicatively disabled, mentally disabled, and physically disabled. Frail elderly
Older adults or aged individuals who are lacking in general strength and are unusually susceptible to disease or to other infirmity. Homeless
Persons who have no permanent residence, including children and adolescents with no fixed place of residence. Illiterate/low-literate populations
Persons with low levels of education. Immigrants
Persons coming into a country of which he or she is not a native for the purpose of setting up residence. This category is also defined to include refugees, asylees, and undocumented aliens or immigrants. Medically uninsured
Individuals or groups with no or inadequate health insurance coverage. Those falling into this category usually comprise three primary groups: the medically indigent, those with clinical conditions that make them medically uninsurable, and the working uninsured. Mentally ill
Persons diagnosed as having a syndrome of emotional, cognitive, and/or perceptual problems leading to significant impairment of functioning or behavior. Minority groups
A subgroup having special characteristics within a larger group, often bound together by special ties which distinguish it from the larger group. Non-English speaking populations
Individuals who do not speak English or whose primary language is not English. Poverty populations
Persons living below the standard level of living of the community. Prisoners
Individuals involuntarily confined in a penal institution, including persons sentenced under a criminal or civil statute; detained pending arraignment, trial, or sentencing; and detained in other facilities under statutes or commitment procedures providing alternative to criminal prosecution or incarceration in a penal institution. Rural populations
Persons inhabiting rural areas or small towns classified as rural. Terminally ill
Persons with an incurable or irreversible illness at the end stage that will result in death within a short time. Transients/migrants
Mobile, short-term residents who move, usually to find work. Urban populations
Persons inhabiting a city or town, including metropolitan areas. Women
Adult females including working women (who are engaged in gainful activities usually outside the home), battered women (who are physically and mentally abused over an extended period), and pregnant women.