Quality Works

Quality Works® is a performance measurement system software and patient safety data collection tool from the MHA Management Services Corporation that helps hospitals collect, report and analyze clinical quality data. Hospitals also use the Quality Works® core measure module to collect and transmit data to the Joint Commission.

  • About
  • Features
  • Measures
  • Advantages

Quality Works® is a Web-based data collection tool that is user-friendly, intuitive and efficient. The patient population for core measures is defined by the software for inclusion/exclusion criteria. Quality Works® has embedded algorithms that decrease the abstraction time necessary for data collection by limiting data entry to the required data elements specific to each case.

Real-time reporting provides immediate feedback on performance for hospital quality improvement opportunities. Quality Works® facilitates other quality improvement initiatives through user-defined data collection fields. Web-based reports with graphing, trending and statistical capability are available immediately to users. In addition, national comparison reports for core measures can be exported to other databases and statistical packages for internal use. Quality Works® physician reports support collection and analysis of data sorted by admitting and attending physicians, surgeons or other physicians.

Quality Works® is a cost-effective option that allows acute care hospitals or critical access hospitals to collect and report defined data sets for internal quality improvement and benchmarking purposes.

  • web-based software for data collection and submission
  • user-friendly data entry features
  • collection of data for all core measure sets
  • online data editing and transmission
  • capable of integrating data from established hospital systems
  • Missouri-based customer support and service
  • consultation on data use for quality improvement programs
  • export via the Internet all data entered
  • export all data

Joint Commission's Core Measures

The Joint Commission began requiring accredited hospitals to collect and submit core measure data in July 2002. If your hospital treats patients with any of the conditions outlined in the core measure, it must select a performance measurement system vendor to process and transmit its core measures to the Joint Commission.

  • immunizations
  • tobacco
  • perinatal care
  • substance abuse
  • hospital-based inpatient psychiatric services
  • emergency department
  • outpatient care measures
  • venous thromboembolism
  • stroke

CMS' Hospital Quality Reporting Requirements

The Quality Works® Centers for Medicare & Medicaid Services module helps hospitals collect data for the CMS’ hospital quality reporting requirements.

  • sepsis
  • immunizations
  • emergency department
  • outpatient care measures
  • venous thromboembolism
  • stroke
  • hospital-based inpatient psychiatric services
  • other measure sets as implemented by the CMS

Core Measures

Inpatient (IP)

Tobacco Treatment (TOB)
tobacco use screening
tobacco use treatment provided or offered
tobacco use treatment provided or offered at discharge

Substance Use (SUB)
alcohol use screening
alcohol use brief intervention provided or offered
alcohol and other drug use disorder treatment provided or offered at discharge

Perinatal Care (PC)
elective delivery
cesarean section
antenatal steroids
health care-associated bloodstream infections in newborns
exclusive breast milk feeding

Hospital Based Inpatient Psychiatric Services (HBIPS)
admission screening for violence risk, substance use, psychological trauma history and patient strengths completed
hours of physical restraint use
hours of seclusion use
patients discharged on multiple antipsychotic medications with appropriate justification

Venous Thromboembolism (VTE)
VTE discharge instructions
incidence of potentially-preventable VTE

Stroke (STK)
VTE prophylaxis
discharged on antithrombotic therapy
anticoagulation therapy for atrial fib/flutter
thrombolytic therapy
antithrombic therapy by end of hospital day 2
discharged on statin medication
stroke education
assessed for rehabilitation

Emergency Department (ED)
median time from ED arrival to ED departure for admitted ED patients
admit decision time to ED departure time for admitted patients

Immunization (IMM)
influenza immunization

Sepsis Bundle Project (SEP)
early management bundle, severe sepsis/septic shock

Outpatient (OP)

Acute Myocardial Infarction (AMI)
median time to fibrinolysis
fibrinolytic therapy received within 30 minutes
median time to transfer to another facility for Acute Coronary Intervention
aspirin at arrival
median time to ECG

Chest Pain (CP)
aspirin at arrival
median time to ECG

ED Throughput (TPT)
median time from ED arrival to ED departure for discharged ED patients
door to diagnostic evaluation by a qualified medical personnel

Pain Management (PM)
median time to pain management for long bone fracture

Stroke (STK)
head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan interpretation within 45 minutes of ED arrival

  • experience as a vendor since 1997
  • experience as a participant in the core measure national pilot project
  • cost-effective solution for hospitals’ performance measurement needs