Attachment C - Maternity Care Measures Inventory.xlsx

	A	B	C	D	E	F	G	H	I	J	K	L	M	N
1	Measure Name	Perinatal Phase (Prenatal, Birth, Postpartum)	NQF #	Endorsement Status	Endorsing Agency	Source	In Leapfrog Hospital Survey's set?	In PBGH San Diego episode set?	In 2022 CMS Maternity Core Set?	In Bailit Health recommended set?	MFM/OB Hospitalist Mednax Metrics?	Newborn / NICU Mednax Metrics?	HQIP Measure set?	HCPF Maternity Bundle Year 2 Measures?

2	PC-01: Elective Delivery (PC01-AD)	Birth	0469/0469e	Endorsed	TJC	Hybrid or EHR	X				X
3	Incidence of Episiotomy (Provider-Level)	Birth	0470	Endorsed	AMA-PCPI	Claims/Clinical	X				X		X
4	Cesarean Rate for Nulliparous Singleton Vertex (PC-02)	Birth	0471	Endorsed	TJC	Claims/Clinical	X	X		X	X		X
5	Newborn Bilirubin Screening Prior to Discharge	Birth	n/a	n/a	n/a		X
6	Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery	Birth	0473	No Longer Endorsed	Hospital Corporation of America	Clinical	X				X
7	NICU volume of very-low birthweight babies (VLBWBs) or Vermont Oxford Network's (VON) measure of death or morbidity	Birth	n/a	n/a	Vermont Oxford Network		X
8	Percentage of Deliveries by Certified Nurse Midwife	Birth	n/a	n/a	CMQCC	CDPH - Vital Records		X
9	Prenatal Depression Screening and Follow-Up (PND)	Prenatal	n/a	No Longer Endorsed	NCQA			X
10	Postpartum Depression Screening and Follow-Up (PPD)	Postpartum	n/a	No Longer Endorsed	NCQA			X						X
11	Unexpected Newborn Complications in Term Infants	Birth	0716	Endorsed	CMQCC	Claims		X						X
12	Preterm Birth	Birth	n/a	n/a	n/a			X
13	Live Births Weighing Less Than 2,500 Grams (LBW-CH)	Birth	1382	Endorsed	CDC	State Vital Records		X	X					X
14	Patient Experience Survey Questionnaire (Press Ganey)	Patient	n/a	n/a	Press Ganey			X
15	Prenatal and Postpartum Care: Postpartum Care (PPC-AD)	Postpartum	1517	No Longer Endorsed	NCQA	Administrative or Hybrid			X	X
16	Contraceptive Care - Postpartum Women Ages 21 to 44 (CCP-AD)	Postpartum	2902	Endorsed	OPA	Administrative			X					X
17	Contraceptive Care - All Women Ages 21 to 44 (CCW-AD)	Postpartum	2903/2904	Endorsed	OPA	Administrative			X
18	Well-Child Visits in the First 30 Months of Life (W30-CH)	Postpartum	1392	Endorsed	NCQA	Administrative			X
19	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-CH)	Prenatal	1517	No Longer Endorsed	NCQA	Administrative or Hybrid			X	X
20	Contraceptive Care - Postpartum Women Ages 15 to 20 (CCP-CH)	Postpartum	2902	Endorsed	OPA	Administrative			X					X
21	Contraceptive Care - All Women Ages 15 to 20 (CCW-CH)	Prenatal	2903/2904	Endorsed	OPA	Administrative			X
22	Low-Risk Cesarean Delivery (LRCD-CH)	Birth	n/a	n/a	CDC	State Vital Records			X
23	Behavioral Health Risk Assessment (for Pregnant Women)	Behavioral	n/a	n/a	AMA-PCPI	Clinical				X
24	Appropriate Use of Antenatal Steroids (PC-03)	Birth	0476	No Longer Endorsed	TJC	Claims/Clinical				X
25	Screening for Group B Streptococcus (GBS)	Birth	n/a	n/a	n/a	Claims/Clinical				X
26	Chorionicity documented at the first ultrasound exam in twin pregnancy	Prenatal	n/a	n/a	ACOG, AIUM, ACR						X
27	Umbilical artery Doppler performed for fetus with suspected growth restriction	Birth	n/a	n/a	ACOG						X
28	Postpartum GTT ordered and results obtained for patient with gestational diabetes	Birth	n/a	n/a	ACOG						X
29	Low dose Aspirin recommended for patient with history of preeclampsia in prior pregnancy	Birth	n/a	n/a	United States Preventive Services Task Force						X
30	17-Hydroxyprogesterone Caproate initiated at 16-21 weeks for patient history with spontaneous preterm birth of singleton in prior pregnancy	Birth	n/a	n/a	ACOG						X
31	Incidence of 3rd or 4th degree Perineal Laceration	Birth	n/a	n/a	AHRQ						X
32	Birth trauma per 1000 newborns	Birth	0474	Never Endorsed	AHRQ	Claims					X
33	Prophylactic antibiotic prior to cesarean section	Birth	0472	No Longer Endorsed	Massachusetts General Hospital	Claims/Clinical					X
34	Preventable Readmissions of Newborns	Birth	n/a	n/a	CMS							X
35	Hearing Screening Prior to Hospital Discharge	Birth	1354	Endorsed	CDC	Clinical						X
36	Severe ROP	Birth	n/a	n/a	NQF							X
37	NEC (Surgical)	Birth	n/a	n/a	NQF							X
38	Severe IVH	Birth	n/a	n/a	NQF							X
39	Breast Milk at Discharge	Birth	n/a	n/a	TJC, NQF							X
40	Breast Milk in First Week	Birth	n/a	n/a	TJC, NQF							X
41	Late Onset Sepsis (Positive Blood Culture >3 days)	Late	n/a	n/a	CDC							X
42	Hypothermia on Admission (Admit Temp <36)	Birth	n/a	n/a	NQF							X
43	Hepatitis B Vaccine	Birth	n/a	n/a	CDC							X
44	Perinatal Depression and Anxiety	Birth	n/a	n/a	Council on Patient Safety in Women's Health Care								X
45	Maternal Emergencies	Birth	n/a	n/a	National Partnership for Maternal Safety	Clinical							X
46	Reduction of Peripartum Racial and Ethnic Disparities	Birth	n/a	n/a	Council on Patient Safety in Women's Health Care	Clinical							X
47	Reproductive Life/Family Planning	Birth		n/a	HCPF / US Office of Population Affairs	Clinical							X
48	Zero Suicide	Birth	n/a	n/a	CDPHE	Clinical							X
49	Clostridium difficile (C. Diff)	Birth	1717	Endorsed	CDC	Clinical							X
50	Sepsis	Birth	n/a	n/a	HQIP	Clinical							X
51	Antibiotics Stewardship	Birth	n/a	n/a	CDPHE	Clinical							X
52	Adverse Event	Birth	n/a	n/a	HQIP	Clinical							X
53	Culture of Safety Survey	Birth	n/a	n/a	AHRQ	Clinical							X
54	Handoffs and Signouts	Birth	n/a	n/a	HQIP	Clinical							X
55	HCAHPS	Birth	0166	Endorsed	AHRQ/CMS	Clinical							X
56	Advance Care Plan	Birth	0326	Endorsed	NCQA	Clinical							X
57	Severe Maternal Morbidity	Birth	n/a	n/a	n/a	Clinical								X
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