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Previous Page
  • Table of Contents
    • Contents
    • Executive Summary
    • Background
    • Methods
    • Next Steps
    • References
    • Appendixes
    • Members of the AHRQ NAC Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs
    • Appendix TablesOnline Measure Nominations Template
    • Instructions for Delphi Round 2 for AHRQ SNAC Members
    • One-page Summary Template
  • Download
    • PDF file PDF version - 480.54 KB

Appendix 5: One-Page Summary Template

SNAC-recommended Initial Core Set, September 18, 2009

Measure Summary: CHIPRA Core Set Candidate Measures

  1. Control #:
  2. Measure Name:
  3. Measure Definition
    1. Numerator:
    2. Denominator:
  4. Measure Type:
    ____  Process ____  Outcome ____  Structure ____  Efficiency

  5. Measure collected using:
    ____ EMR ____ CPOE ____  Other HIT ____ N/A ____ NR

    VALIDITY

  6. Evidence of measure validity submitted?
    ____ Yes ____ No
  7. Level of evidence supporting the measure (if submitted): (see Oxford University CEBM Levels of Evidence)
    __________________________________________________ 

  8. USPSTF Grade if applicable:
    __________________________________________________ 

    FEASIBILITY

  9. Measure Specifications Submitted?
    ____  Yes ____ No____ Yes, but insufficient detail provided
  10. Data Source:
    ____ Admin____  MR____ Survey____ Other (specify):____ NR
  11. Evidence of measure reliability submitted?
    ____ Yes____ No

  12. List of entity types currently using measure:
    __________________________________________________ 

    IMPORTANCE

  13. Addresses area of care mandated in legislation?
    ____ Yes (specify): __________________________________________________ ____ No
  14. Documented variation in performance (by race/ethnicity, language spoken, insurance type, etc)?
    ____ Yes____ No____ NR
  15. Measure used/data are collected in racial/ethnic populations other than non-Hispanic white?
    ____ Yes____ No____ NR
Page last reviewed January 2010
Internet Citation: Appendix 5: One-Page Summary Template: SNAC-recommended Initial Core Set, September 18, 2009. January 2010. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/policymakers/chipra/coreset/coresetap5.html

 

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