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Measures Stewarded Externally
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Measures Stewarded Externally

PCPI is a leader in the development and maintenance of clinical performance measures.

In an effort to ensure the PCPI’s continued leadership in the development of next generation measures and to more effectively support PCPI members in their measure development and maintenance efforts, PCPI restructured its measure development model in 2013. PCPI adopted a more decentralized model for measure maintenance, providing PCPI members with the opportunity to directly manage the currency of performance measures relevant to their constituents. Measures developed by PCPI which are now stewarded and maintained by our partners in measure development are available in the following clinical conditions or topic areas:

Acute Otitis Externa/Otitis Media with Effusion

American Academy of Otolaryngology — Head and Neck Surgery

  • Acute Otitis Externa: Pain Assessment
  • Acute Otitis Externa: Systemic Antimicrobial Therapy — Avoidance of Inappropriate Use
  • Acute Otitis Externa: Topical Therapy
  • Otitis Media with Effusion: Diagnostic Evaluation — Assessment of Tympanic Membrane Mobility
  • Otitis Media with Effusion: Hearing Testing
  • Otitis Media with Effusion: Antihistamines or Decongestants — Avoidance of Inappropriate Use
  • Otitis Media with Effusion: Systemic Antimicrobials — Avoidance of Inappropriate Use
  • Otitis Media with Effusion: Systemic Corticosteroids — Avoidance of Inappropriate Use

Anesthesiology and Critical Care

American Society of Anesthesiologists

  • Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
  • Perioperative Temperature Management
  • Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
  • Prevention of Post-Operative Nausea and Vomiting (PONV) — Combination Therapy for Adults at High Risk for PONV
  • Prevention of Post-Operative Vomiting (POV) — Combination Therapy for Pediatric Patients at High Risk for POV
  • Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents (Quality Improvement Only)
  • Surgical Safety Checklist — Applicable Safety Checks Completed Before Induction of Anesthesia


American Academy of Allergy, Asthma and Immunology

  • Asthma Discharge Plan
  • Assessment of Asthma Control
  • Assessment of Asthma Risk
  • Pharmacologic Therapy for Persistent Asthma
  • Tobacco Smoke Exposure: Screening
  • Tobacco Smoke Exposure: Intervention
  • Asthma Action Plan

Chronic Obstructive Pulmonary Disease

American Thoracic Society

  • Spirometry Evaluation
  • Inhaled Bronchodilator Therapy

Chronic Wound Care

American Society of Plastic Surgeons

  • Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse)
  • Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulers (Overuse)
  • Assessment of Wound Characteristics in Patients Undergoing Debridement
  • Offloading (Pressure Relief) of Diabetic Foot Ulcers
  • Patient Education Regarding Diabetic Foot Care
  • Patient Education Regarding Long Term Compression Therapy
  • Use of Compression System in Patients with Venous Ulcers


American Academy of Neurology and American Psychiatric Association

  • Palliative Care Counseling and Advance Care Planning
  • Caregiver Education and Support
  • Counseling Regarding Risks of Driving
  • Counseling Regarding Safety Concerns
  • Functional Status Assessment
  • Management of Neuropsychiatric Symptoms
  • Neuropsychiatric Symptom Assessment
  • Screening for Depressive Symptoms
  • Staging of Dementia

Emergency Medicine

American College of Emergency Physicians

  • American College of Emergency Physicians
  • Aspirin at Arrival for AMI
  • Electrocardiogram Performed for Non-Traumatic Chest Pain
  • Electrocardiogram Performed for Syncope
  • Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
  • Vital Signs for Community-Acquired Bacterial Pneumonia
  • Assessment for Oxygen Saturation for Community-Acquired Bacterial Pneumonia
  • Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
  • Care Coordination for PCI (QI)
  • Fibrinolytic Therapy Ordered Within 20 Minutes of ECG Performed for AMI (QI)

Eye Care

American Academy of Ophthalmology  

  • Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure by 15% or Documentation of a Plan of Care
  • Primary Open-Angle Glaucoma (POAG): Counseling on Glaucoma
  • Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
  • Age-Related Macular Degeneration: Dilated Macular Examination
  • Cataracts: Comprehensive Pre-operative Assessment for Cataract Surgery with Intraocular (IOL) Placement


American Society of Hematology

  • Chronic Lymphocytic Leukemia: Baseline Flow Cytometry
  • Multiple Myeloma: Treatment with Biphosphonates
  • Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy
  • Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenic Testing Performed on Bone Marrow

Hepatitis C

American Gastroenterological Association

  • Confirmation of Hepatitis C Viremia
  • HCV RNA Testing Before Initiating Treatment
  • HCV Genotype Testing Prior to Treatment
  • HCV Ribonucleic Acid (RNA) Testing at Between 4-12 Weeks After Initiation of Treatment
  • Hepatitis A Vaccination
  • Hepatitis B Vaccination
  • Discontinuation of Antiviral Therapy for Inadequate Viral Response
  • Sustained Virological Response SVR (QI)
  • Discussion and Shared Decision Making Surrounding Treatment Options
  • Screening for HCC in Patients with Hepatitis C Cirrhosis

Kidney Disease- Adult

Renal Physicians Association

  • Advance Directives Completed
  • Arteriovenous Fistula Rate
  • Blood Pressure Management
  • Catheter Use at Initiation of Hemodialysis
  • Catheter Use for >= 90 days
  • ESRD Patients Receiving Dialysis: Hemoglobin Level <10g/dL
  • Hemodialysis Adequacy: Solute
  • Patients on Erythropoiesis Stimulating Agent (ESA)-Hemoglobin Level >12.0 g/dL
  • Peritoneal Dialysis Adequacy: Solute
  • Advance Care Planning
  • Referral to Hospice
  • Referral to Nephrologist
  • Transplant Referral
  • Laboratory Testing (Lipid Profile)
  • Adequacy of Volume Management
  • Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy

Kidney Disease- Pediatric

Renal Physicians Association

  • ESRD Patients Receiving Dialysis: Hemoglobin Level <10g/dL
  • Discussion of Advance Care Planning
  • Adequacy of Volume Management

Major Depressive Disorder- Adult

American Psychiatric Association

  • Coordination of Care of Patients with Specific Comorbid Conditions
  • Comprehensive Depression Evaluation: Diagnosis and Severity
  • Depression Care Follow Up: Assessment of Response to Treatment
  • Depression Care Follow Up: Three Visits in 90 Days Following Diagnosis
  • Patient Education
  • Treatment for Depression

Major Depressive Disorder- Child and Adolescent

American Psychiatric Association

  • Diagnostic Evaluation
  • Follow-up Care
  • Interview of an Adolescent or Child
  • Medications Considered
  • Psychotherapy

Maternity Care

Centers for Medicare & Medicaid Services

  • Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks
  • Post-Partum Follow-up and Care Coordination


American Academy of Dermatology

  • Overutilization of Imaging Studies in Melanoma
  • Melanoma Continuity of Care — Recall System
  • Melanoma Coordination of Care
  • Melanoma Follow-up Aspects of Care

Non-Cardiac Diagnostic Imaging/Radiology

American College of Radiology

  • Stenosis Measurement in Carotid Imaging Reports
  • Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms
  • Reminder System for Screening Mammograms
  • Exposure Reported for Procedures Using Fluoroscopy
  • Utilization of Ultrasonography in Children with Clinically Suspected Appendicitis
  • Radiation Consideration for Adult CT: Utilization of Dose Reduction Techniques
  • Appropriate Use of Imaging for Non-Traumatic Shoulder Pain
  • Appropriate Use of Imaging for Non-Traumatic Knee Pain
  • Use of Premedication Before Contrast-Enhanced Imaging Studies in Patients with Documented Contrast Allergy
  • Extravasation of Contrast Following Contrast-enhanced Computed Tomography (CT)
  • Appropriate Follow-up Imaging for Incidental Simple Ovarian Cysts
  • Appropriate Follow-up Imaging for Incidental Thyroid Nodules
  • Appropriate Follow-up Imaging for Incidental Abdominal Lesions

Nuclear Medicine

Society of Nuclear Medicine and Molecular Imaging

  • Correlation With Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Obstructive Sleep Apnea

American Academy of Sleep Medicine

  • Assessment of Adherence to Positive Airway Pressure Therapy
  • Assessment of Sleep Symptoms
  • Positive Airway Pressure Therapy Prescribed
  • Severity Assessment at Initial Diagnosis


American Society for Radiation Oncology

  • Radiation Dose Limits to Normal Tissues
  • Treatment Summary Communication — Radiation Oncology

American Society of Clinical Oncology

  • Treatment Summary Documented and Communicated — Medical Oncology (QI)
  • Cancer stage Documented
  • Plan of Care for Pain — Medical Oncology and Radiation Oncology
  • Pathology Report
  • Plan for Chemotherapy Documented

Optimizing Patient Exposure to Ionizing Radiation

American College of Radiology

  • Reporting to a Radiation Dose Index Registry
  • Utilization of a Standardized Nomenclature for CT Imaging Description
  • Appropriateness: Follow-up CT Imaging for Incidental Pulmonary Nodules According to Recommended Guidelines
  • Equipment Evaluation for Pediatric CT Imaging Protocols
  • Utilization of Pediatric CT Imaging Protocols
  • Count of Potential High Dose Radiation Imaging Studies: CT Studies and Cardiac Nuclear Medicine Studies
  • Search for Prior CT Studies Through a Secure, Authorized, Media-free, Shared Archive
  • CT Images Available for Patient Follow-up and Comparison Purposes


American Academy of Orthopaedic Surgeons

  • Function and Pain Assessment


College of American Pathologists

  • Breast Cancer Resection Pathology Reporting — pT Category and pN Category with Histologic Grade
  • Colorectal Cancer Resection Pathology Reporting — pT Category and pN Category with Histologic Grade

Perioperative Care

American Society of Anesthesiologists

  • Timing Administration of Prophylactic Parenteral Antibiotics — Administering Physician

American Society of Plastic Surgeons

  • Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
  • Selection of Prophylactic Antibiotic: First OR Second Generation Cephalosporin
  • Venous Thromboembolism (VTE) Prophylaxis

Prostate Cancer

American Urological Association

  • Initial Evaluation
  • Initial Evaluation — New Diagnosis (QI)
  • Treatment Options for Patients with Clinically Localized Disease
  • Adjuvant Hormonal Therapy for High-Risk Patients

Rheumatoid Arthritis

American College of Rheumatology

  • Assessment and Classification of Disease Prognosis
  • Functional Status Assessment
  • Glucocorticoid Management
  • Periodic Assessment of Disease Activity
  • Tuberculosis Screening


American Academy of Otolaryngology — Head and Neck Surgery

  • Antibiotic Prescribed for Acute Sinusitis (Appropriate Use)
  • Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
  • Computerized Tomography for Acute Sinusitis (Overuse)
  • More than 1 Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
  • Plain Film Radiography for Acute Sinusitis (Overuse)
  • Premature Changing of Initial Antibiotic for Acute Bacterial Sinusitis (Overuse)
  • Watchful Waiting for Acute Bacterial Sinusitis: Initial Observation Without Antibiotics for Patients With Mild Illness (Appropriate Use)
  • Accurate Diagnosis of Acute Sinusitis: Distinguishing Viral vs. Bacterial Sinusitis
  • Appropriate Diagnostic Testing for Chronic Sinusitis (Underuse)
  • Patient-Reported Health Status Follow-up for Chronic Sinusitis (QI)
  • Patient-Reported Health Status at Time of Diagnosis for Chronic Sinusitis (QI)

Stroke and Stroke Rehabilitation

American Academy of Neurology

  • Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage
  • Rehabilitation Services Ordered
  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports
  • Imaging for Transient Ischemic Attack or Ischemic Stroke
  • Tissue Plasminogen Activator (t-PA) Considered
  • Tissue Plasminogen Activator (t-PA) Initiated
  • Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge
  • Blood Pressure Management
  • Discharged on Antithrombotic Therapy
  • Lipid Management
  • Potentially Avoidable Harmful Events: Fall with Fracture or Acute Subdural Hematoma (QI)
  • Potentially Avoidable Harmful Events: Stage III or Greater Decubiti (QI)
  • Potentially Avoidable Harmful Events: Urinary Tract Infection (QI)
  • Screening for Dysphagia
  • Artificial Feeding Patient/Caregiver Preferences

Substance Use Disorders

American Psychiatric Association

  • Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence
  • Screening for Depression Among Patients with Substance Abuse or Dependence
  • Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Opioid Addiction

Our Members

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