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For information on reprint and linking permissions, please see RAND Permissions. This product is part of the RAND Corporation technical report series. Reports may include research findings on a specific topic that is limited in scope; present discussions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research professionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for research quality and objectivity. REP O RT RAND/UCLA Quality-of-Care Measures for Carpal Tunnel Syndrome Appendix VII: Quality Measures: Instructions for Analyzing Data Teryl K. NuckolstAnne GriffintSteven M. AschtDouglas A. BennertErika Bruce Mary CassidytWalter T. ChangtNeil G. HarnesstLiisa HiatttCharles K. Jablecki Joanne Jeromet Karl J. SandintRebecca ShawtHaoling H. WengtMelinda Maggard Gibbons Supported by the California Commission on Health and Safety and Workers’ Compensation and by the Zenith Insurance Company C EN T ER F OR HE ALTH A N D S AF ETY IN THE WORKPLACE A study by the RAND Institute for Civil Justice and RAND Health This research was jointly supported by the California Commission on Health and Safety and Workers’ Compensation and by the Zenith Insurance Company, and was undertaken within the RAND Center for Health and Safety in the Workplace. The R AND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. © Copyright 2011 RAND Corporation Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND documents to a non-RAND website is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/ permissions.html). Published 2011 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: [email protected] Appendix VII: Quality Measures: Instructions for Analyzing Data After the Data Forms have been completed, the data will need to be transferred from paper form to electronic form (such as by entering in a database). Next, rates of adherence for each measure will need to be determined, that is, the numerator divided by the denominator. First, the instances in which the eligibility criteria have been met will need to be identified, thereby producing the denominators. Next, the instances in which the adherence criteria have been met will need to be identified, producing the numerators. The table below summarizes the eligibility and adherence criteria for each measure to facilitate these steps in analysis; the rules for identifying the instances of eligibility and adherence are indicated by the term “analysis” within each cell. In addition, there are additional rules that can be used to “double-check” that the responses to different questions are internally consistent. That is, if adherence is based on certain conditions being met, then the variables representing those conditions should show that they are met. Problems with entry of information onto the Data Forms, or transferring the information from paper to electronic form, can involve errors. Checking for consistency across variables and responses is one way of identifying the errors so that they can be corrected. Appendix VII: Quality Measures: Instructions for Analyzing Data VII-1 Measure Title Denominator (Eligibility) Numerator (Adherence) Section 3: CTS as possible cause of symptoms 3.02.M New symptoms characteristic of CTS require detailed assessment 3.03.M New symptoms characteristic of CTS should lead to suspicion Analysis: Analysis: 3.01.ME = 1 3.02.MA = 1 Double check: 3.02.MA = 1 if and only if at least TWO of the following are true: x 3.02.MC.1 = 1 x 3.02.MC.2 = 2 x 3.02.MC.3 = 3 x 3.02.MC.4 = 4 Analysis: Analysis: 3.03.ME = 1 3.03.MA = 1 Double check: 3.03.ME = 1 only if 3.01.ME = 1 Section 4: Symptoms and signs of CTS vs. other conditions 4.01.M New hand or forearm pain requires evaluation for “red flags” 4.02.M New suspicion of CTS requires specific physical examination Analysis: Analysis: 4.01.ME = 1 4.01.MA = 1 Double check: 4.01.MA = 1 if and only if at least ONE of the following is true: x 4.01.MC.1 = 1 x 4.01.MC.2 = 2 x 4.01.MC.3 = 3 Analysis: Analysis: 4.02.ME = 1 4.02.MA = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data Double check: 4.02.MA = 1 if and only if at least ONE of the following is true: x 4.02.MC.1 = 1 x 4.02.MC.2 = 2 x 4.02.MC.3 = 3 VII-2 Measure Title Denominator (Eligibility) Numerator (Adherence) Analysis: Analysis: 4.03.ME = 1 4.03.MA = 1 Analysis: Analysis: 5.01.ME = 1 5.01.MA = 1 6.01.M New suspicion of CTS requires evaluation for excessive weight Analysis: Analysis: 6.01.ME = 1 6.01.MA = 1 6.03.M New CTS diagnosis requires assessment of medical risk factors Analysis: Analysis: 6.02.E = 1 6.03.MA = 1 Double check: Double check: 6.02.E = 1 only if 7.02.E = 1 6.03.MA = 1 if and only if at least ONE of the following is true: 4.03.M New symptoms inconsistent with CTS require evaluation Section 5: Imaging Studies 5.01.M Imaging should be used selectively for suspected CTS Section 6: NonOccupational Risk Factors and Exacerbating Factors 6.04.M New CTS diagnosis requires assessment of nonoccupational factors x 6.03.MC.1 = 1 x 6.03.MC.2 = 2 x 6.03.MC.3 = 3 x 6.03.MC.4 = 4 x 6.03.MC.5 = 5 Analysis: Analysis: 6.02.E = 1 6.04.MA = 1 Double check: Double check: 6.02.E = 1 only if 7.02.E = 1 6.04.MA = 1 if and only if at least ONE of the following is true: Appendix VII: Quality Measures: Instructions for Analyzing Data x 6.04.MC.1 = 1 x 6.04.MC.2 = 2 x 6.04.MC.3 = 3 VII-3 Section 7: WorkAssociated CTS Symptoms 7.03.M New CTS diagnosis requires detailed occupational history 7.04.M New CTS diagnosis requires assessment of occupational factors Double check: All Measures in Section 7 are eligible only if the following is true: o 7.01.E = 1 Analysis: Analysis: 7.02.ME = 1 7.03.MA = 1 Double check: 7.03.MA = 1 if and only if at least ONE of the following is true: x 7.03.MC.1 = 1 x 7.03.MC.2 = 2 x 7.03.MC.3 = 3 x 7.03.MC.4 = 4 Analysis: Analysis: 7.04.ME = 1 7.04.MA = 1 Double check: Double check: 7.04.ME = 1 only if 7.02.E = 1 7.04.MA = 1 if and only if at least ONE of the following is true: x 7.04.MC.1 = 1 x 7.04.MC.2 = 2 x 7.04.MC.3 = 3 7.05.M Exacerbating activities should be identified when symptoms limit functioning Analysis: Analysis: 7.05.ME = 1 7.05.MA = 1 7.06.M. Rationale for work-association should be documented Analysis: Analysis: 7.06.ME = 1 7.06.MA = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-4 8.01.M Patients newly diagnosed with CTS should be educated about the condition Analysis: Analysis: 8.01.ME = 1 8.01.MA = 1 Double check: 8.01.MA = 1 if and only if at least one of the following is true: x 8.01.MC.1 = 1 x 8.01.MC.2 = 2 x 8.01.MC.3 = 3 x 8.01.MC.4 = 4 x 8.01.MC.5 = 5 x 8.01.MC.6 = 6 x 8.01.MC.7 = 7 x 8.01.MC.8 = 8 8.02.M Exposures to vibration, force, and repetition should be minimized Analysis: Analysis: 8.02.ME = 1 8.02.MA =1 8.04.M Splints should be placed in neutral position. Analysis: Analysis: 8.03.E = 1 8.04.MA =1 8.05.M An attempt at splinting should last at least six weeks Analysis: Analysis: 8.05.ME =1 8.05.MA =1 Double check: 8.05.ME = 1 only if 8.03.E = 1 8.07.M NSAIDs should not be used for CTS Analysis: Analysis: 8.06.E =1 8.07.MA = 1 8.08.M Muscle relaxants should not be used for CTS Analysis: Analysis: 8.06.E =1 8.08.MA = 1 8.09.M Opiates should not be used for CTS Analysis: Analysis: 8.06.E =1 8.09.MA = 1 8.10.M Diuretics should not be used for CTS Analysis: Analysis: 8.06.E =1 8.10.MA = 1 8.11.M Steroid treatment requires discussion of risks Analysis: Analysis: 8.11.ME = 1 8.11.MA = 1 Double check: 8.11.ME = 1 only if 8.06.E = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-5 8.12.M Discuss benefits of surgery when offering steroids to patients with severe CTS Analysis: Analysis: 8.12.ME = 1 8.12.MA = 1 8.13.M Limit steroid injections to four Analysis: Analysis: 8.13.ME = 1 8.13.MA = 1 Double check: 8.12.ME = 1 only if 8.06.E = 1 Double check: 8.13.ME = 1 only if 8.06.E = 1 8.14.M Laser therapy should not be used for CTS Analysis: Analysis: 8.14.ME = 1 8.14.MA = 1 Double check: Section 9: Follow-up All Measures in section are eligible only if 7.01.E = 1 9.01.M Symptoms should be monitored after new diagnosis of CTS Analysis: Analysis: 9.01.ME = 1 9.01.MA = 1 Double check: 9.01.MA = 1 if and only if at least one of the following is true: x 9.01.MC.1 = 1 x 9.01.MC.2 = 2 9.03.M Workassociated CTS symptoms require prompt follow-up Analysis: Analysis: 9.03.ME = 1 9.03.MA = 1 9.04.M Work status should be monitored when CTS appears work-associated Analysis: Analysis: 9.04.ME = 1 9.04.MA = 1 9.05.M Steroids for work-associated symptoms require follow-up Analysis: Analysis: 9.05.ME = 1 9.05.MA = 1 9.07.M Return to work after CTS-related disability requires follow-up assessment that includes functional limitations Analysis: Analysis: 9.07.ME = 1 9.07.MA = 1 Double check: 9.03.ME = 1 only if 9.02.E = 1 Double check: 9.04.ME = 1 only if 9.02.E = 1 Double check: 9.05.ME = 1 only if 9.02.E = 1 Double check: 9.07.ME = 1 only if 9.06.E = 1 9.07.ME = 1 only if 9.02.E = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-6 9.08.M Prolonged CTS-related disability should trigger evaluation Analysis: Analysis: 9.06.E = 1 9.08.MA = 1 Double check: Double check: 9.06.E = 1 only if 9.02.E = 1 9.08.MA = 1 if and only if at least ONE of the following are true: x 9.08.MC.1 = 1 x 9.08.MC.2 = 2 x 9.08.MC.3 = 3 Double check: Section 10: Surgical Decision-making All Measures in section are eligible only if all of the following are true: x 7.01.E = 1 x 10.01.E = 1 or 2 x 10.02.E = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-7 10.09.V Severity Summary Double check: 10.09.V = 1 if and only if all of the following are true: x 10.04.V.Summary = 1, AND x 10.06.V.Summary = 1 10.09.V = 2 if and only if all of the following are true: x 10.04.V.Summary = 1 or 2, AND x 10.06.V.Summary = 2, AND x At least one of the following: o 10.05.V.Summary = 1 OR o 10.07.V.Summary = 1 OR o 10.08.V.Summary = 1 10.09.V = 3 if and only if all of the following are true: 10.10.V Probability Summary x 10.04.V.Summary = 1 or 2, AND x 10.05.V.Summary = 2, AND x 10.06.V.Summary = 2, AND x 10.07.V.Summary = 2, AND x 10.08.V.Summary = 2, AND Double check: 10.10.V = 1 if and only if either of the following is true: x x For moderate or severe CTS (10.09.V = 1 or 2): o 10.04.V.Summary = 1, AND o 10.07.V.Summary OR 10.08.V.Summary = 1 For mild CTS (10.09.V = 3): o Appendix VII: Quality Measures: Instructions for Analyzing Data 10.04.V.Summary = 1 VII-8 Double check: Section 11: Compelling Indications for CTR All Measures in section are eligible only if all of the following are true: x 7.01.E = 1 x 10.01.E = 1 or 2 x 10.02.E = 1 11.01.M Indications for carpal tunnel surgery are not changed by diabetes Analysis: Analysis: 11.01.ME = 1 11.01.MA = 1 11.02.M Prompt surgery in wrist injury Analysis: Analysis: 11.02.ME = 1 11.02.MA = 1 Double check: If 6.03.MC.2 = 2 then 11.01.ME should = 1 Double check: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery 11.03.M Compelling indications for surgery when CTS is MILD 11.04.M Compelling indications for surgery when CTS is MODERATE, Part I Analysis: Analysis: 11.03.ME = 1 11.03.MA = 1 Double check: Double check: 11.03.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery x 10.09.V = 3, AND x 10.10.V = 1, AND x 10.11.V = 1, AND x 10.12.V = 1, AND Analysis: Analysis: 11.04.ME = 1 11.04.MA = 1 Double check: Double check: 11.04.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery x 10.09.V = 2, AND x 10.10.V = 1, AND x 10.11.V = 1, AND x 10.12.V = 1, AND x 10.13.V = 2 or 3 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-9 11.05.M Compelling indications for surgery when CTS is MODERATE, Part II 11.06.M Compelling indications for surgery when CTS is SEVERE, part I 11.07.M Compelling indications for surgery when CTS is SEVERE, part II 11.08.M Compelling indications for surgery when CTS is SEVERE, part III Analysis: Analysis: 11.05.ME = 1 11.05.MA = 1 Double check: Double check: 11.05.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery x 10.09.V = 2, AND x 10.10.V = 1 AND/OR 10.11.V = 1, AND x 10.12.V = 1, AND x 10.13.V = 1 Analysis: Analysis: 11.06.ME = 1 11.06.MA = 1 Double check: Double check: 11.06.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined CTR x 10.09.V = 1, AND x 10.10.V = 1, AND x 10.12.V = 1, Analysis: Analysis: 11.07.ME = 1 11.07.MA = 1 Double check: Double check: 11.07.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery x 10.09.V = 1, AND x 10.10.V = 1, AND x 10.11.V = 1, AND x 10.12.V = 2 or 4, AND x 10.13.V = 3 Analysis: Analysis: 11.08.ME = 1 11.08.MA = 1 Double check: Double check: 11.08.ME = 1 if and only if all of the following are true: 10.01.E = 1 for most patients, some exceptions are plausible for patients who declined surgery x 10.09.V = 1, AND x 10.10.V = 1, AND x 10.11.V = 1, AND x 10.12.V = 2 or 4, AND x 10.13.V = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-10 Double check: Section 12: Compelling Contraindications to CTR 12.01.M Avoidance of carpal tunnel surgery during pregnancy 12.02.M Compelling CONTRA-indications for surgery when CTS is MILD, part I 12.03.M Compelling CONTRA-indications for surgery when CTS is MILD, part II All Measures in section are eligible only if all of the following are true: x 7.01.E = 1, AND x 10.01.E = 1 or 2, AND x 10.02.E = 1 Analysis: Analysis: 12.01.ME = 1 12.02.MA = 1 Double check: Double check: If 6.03.MC.4 = 4 then 12.01.ME should = 1 Either 10.01.E = 2; OR 10.01.E = 1 AND all of the following are true: x 12.02.MC.1 = 1, AND x 12.02.MC.2 = 2, AND x 12.02.MC.3 = 3 Analysis: Analysis: 12.02.ME = 1 10.01.E = 2 Double check: 12.02.ME = 1 if and only if all of the following are true: x 10.09.V = 3, AND x 10.10.V = 2 AND/OR 10.11.V = 2, AND x 10.12.V = 2, 3, or 4 Analysis: Analysis: 12.03.ME = 1 10.01.E = 2 Double check: 12.03.ME = 1 if and only if all of the following are true: x 10.09.V = 3, AND x 10.10.V = 2, AND x 10.11.V = 2, AND x 10.12.V = 1, AND x 10.13.V = 2 or 3 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-11 12.04.M Compelling CONTRA-indications for surgery when CTS is MODERATE, part I 12.05.M Compelling CONTRA-indications for surgery when CTS is MODERATE, part II 12.06.M Compelling CONTRA-indications for surgery when CTS is MODERATE, part III 12.07.M Compelling CONTRA-indications for surgery when CTS is MODERATE, part IV Analysis: Analysis: 12.04.ME = 1 10.01.E = 2 Double check: 12.04.ME = 1 if and only if all of the following are true: x 10.09.V = 2, AND x 10.10.V = 2 AND/OR 10.11.V = 2, AND x 10.12.V = 2, 3 or 4, AND x 10.13.V = 3 Analysis: Analysis: 12.05.ME = 1 10.01.E = 2 Double check: 12.05.ME = 1 if and only if all of the following are true: x 10.09.V = 2, AND x 10.10.V = 2, AND x 10.11.V = 2, AND x 10.12.V = 1, AND x 10.13.V = 3 Analysis: Analysis: 12.06.ME = 1 10.01.E = 2 Double check: 12.06.ME = 1 if and only if all of the following are true: x 10.09.V = 2, AND x 10.10.V = 2 AND/OR 10.11.V = 2, AND x 10.12.V = 3, AND x 10.13.V = 1 or 2 Analysis: Analysis: 12.07.ME = 1 10.01.E = 2 Double check: 12.07.ME = 1 if and only if all of the following are true: x 10.09.V = 2, AND x 10.11.V = 2, AND x 10.12.V = 2 or 4, AND x 10.13.V = 1 or 2 Appendix VII: Quality Measures: Instructions for Analyzing Data VII-12 Analysis: Section 13: Perioperative Care All Measures in section are eligible only if 10.01.E = 1 Double check: All measures in this section are eligible only if 7.01.E = 1 Analysis: 13.01.M Elements of CTS-specific surgical evaluation 13.01.MA = 1 Double check: 13.01.MA = 1 if and only if ALL of the following are true: x 13.01.MC.1 = 1, AND x 13.01.MC.2 = 2, AND x 13.01.MC.3 = 3 Analysis: 13.02.M Documentation of prior treatments for CTS 13.02.MA = 1 13.03.M Preoperative evaluation of suspected cervical radiculopathy Analysis: Analysis: 13.03.ME = 1 13.03.MA = 1 13.04.M Preoperative electrodiagnostic testing for work associated CTS Analysis: Analysis: 13.04.ME = 1 13.04.MA = 1 Double check: 9.02.E = 1 13.05.M Recent preoperative visit with surgical team Analysis: 13.06.M Elements of general preoperative history: Medical comorbidities Analysis: 13.07.M Elements of general preoperative history: Past surgical history Analysis: 13.08.M Elements of general preoperative history: Current medications Analysis: Appendix VII: Quality Measures: Instructions for Analyzing Data 13.05.MA = 1 13.06.MA = 1 13.07.MA = 1 13.08.MA = 1 VII-13 13.9.M Elements of general preoperative history: “Allergies” Analysis: 13.10.M Elements of general preoperative history: Review of systems including at least two organ systems Analysis: 13.09.MA = 1 13.10.MA = 1 13.11.M Consent for open procedure in planned endoscopic release Analysis: Analysis: 13.11.ME = 1 13.11.MA = 1 13.12.M Requirement for a postoperative visit Analysis: Analysis: 13.12.ME = 1 13.12.MA = 1 13.13.M Elements of postoperative visit with surgical team Analysis: Analysis: 13.13.ME = 1 13.13.MA = 1 13.14.M Monitoring of postoperative stiffness Analysis: Analysis: 13.14.ME = 1 13.14.MA = 1 13.15.M Management of postoperative finger stiffness Analysis: Analysis: 13.15.ME = 1 13.15.MA = 1 13.16.M Patients who do not improve after surgery require evaluation Analysis: Analysis: 13.16.ME = 1 13.16.MA = 1 13.17.M Management of lack of improvement after surgery Analysis: Analysis: 13.17.ME = 1 13.17.MA = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data Double check: 13.17.MA = 1 if and only if at least one of the following is true: x 13.17.MC.1 = 1, OR x 13.17.MC.2 = 2, OR x 13.17.MC.3 = 3 VII-14 Scoring Measures for Electrodiagnosis in Suspected CTS Measure Title EDX.04.M Essential components of electrodiagnostic evaluation for CTS EDX.05.M Skin temperature measured during test EDX.06.M Low skin temperature normalized before electrodiagnostic testing EDX.19.MA Criteria for calling electrodiagnostic test positive for CTS overall EDX.20.M Criteria for calling positive test for CTS severe Denominator (Eligibility) Double check: For all measures in section, all of the following should be true: x 2.03.V = Date (i.e., not missing), AND x EDX.01.E = Date (i.e., not missing), AND x EDX.03.E = 1 Analysis: EDX.02.E = Date Analysis: EDX.02.E = Date Analysis: EDX.06.ME = 1 Double check: EDX.06.ME = 1 if and only if EDX.05.MA = 1 Analysis: EDX.07.E = 1 Analysis: EDX.20.ME = 1 Double check: EDX.07.E = 1 Appendix VII: Quality Measures: Instructions for Analyzing Data Numerator (Adherence) Analysis: EDX.04.MA = 1 Double check: All three of the following must be true: x EDX.04.MC.1 = 1, AND x EDX.04.MC.2 = 2, AND x EDX.04.MC.3 = 3 Analysis: EDX.05.MA = 1 Analysis: EDX.06.MA = 1 Analysis: EDX.19.MA = 1 Double check: At least one of the following must be true: x EDX.10.MC = 1, OR x EDX.13.MC = 1, OR x EDX.16.MC = 1, OR x EDX.18.MC = 1 Analysis: EDX.20.MA = 1 Double check: EDX.20.MA = 1 if and only if both of the following are true x EDX.20.MC.1 = 1, AND x EDX.20.MC.2 = 2 VII-15 Scoring Intraoperative Care Measures Measure Title IOC.02.M Documentation of TCL release IOC.03.M Indications for primary open rather than endoscopic release IOC.04.M Documentation of proximal transverse incision location in endoscopic release IOC.05.M Identification of deep surface of TCL in endoscopic release IOC.06.M Limit superficial epineurotomy to specific indications IOC.07.M Limit internal neurolysis to specific indications IOC.08.M Limit flexor tenosynovectomy to specific indications IOC.09.M Avoidance of TCL repair Denominator (Eligibility) Double check: For all measures in section, all of the following should be true (but additional requirements may also apply): x 7.01.E = 1, AND x 10.01.E = 1, AND x IOC.01.E = 1, 2, or 3 Analysis: IOC.01.E = 1, 2, or 3 Numerator (Adherence) Analysis: IOC.02.MA = 1 Analysis: x IOC.01.E = 1, 2 or 3 x IOC.03.ME = 1, 2 or 3 Double check: IOC.03.ME = 1 if and only if at least one of the following is true: x IOC.03.MC.1 = 1, OR x IOC.03.MC.2 = 2, OR x IOC.03.MC.3 = 3, OR x IOC.03.MC.4 = 4 Analysis: IOC.01.E = 1 or 3 Analysis: IOC.03.MA = 1 Analysis: IOC.05.ME = 1 or 3 Double check: IOC.05.ME = 1 if and only if IOC.01.E = 3 Analysis: IOC.01.E = 2 or 3 Analysis: IOC.05.MA = 1 Analysis: IOC.01.E = 2 or 3 Analysis: IOC.07.MA.01 = 2 OR IOC.07.MA.02 = 1 Analysis: IOC.08.MA.01 = 2 OR IOC.08.MA.02 = 1 Analysis: IOC.01.E = 2 or 3 Analysis: IOC.01.E = 2 or 3 Appendix VII: Quality Measures: Instructions for Analyzing Data Analysis: IOC.04.MA = 1 Double check: IOC.04.MA = 1 if and only if one of the following is true: x IOC.04.MC.1 = 1 x IOC.04.MC.2 = 2 Analysis: IOC.06.MA.01 = 2 OR IOC.06.MA.02 = 1 Analysis: IOC.09.MA = 1 VII-16