NU 623 Unit 7 Quality Measure Gap Analysis Example

Course	NU 623 Adult Healthcare
Unit	Unit 7
Paper type	Quality measure gap analysis
Length	About 1,060 words, 6 pages
Format	APA 7 student paper
School	Herzing University
Program	MSN Family Nurse Practitioner
Updated	October 2026

Free sample paper for NU 623 Unit 7

Controlling High Blood Pressure (CMS165): A Gap Analysis for a Four-Clinician Primary Care Practice

Student Name

Department of Nursing, Herzing University

NU 623: Adult Healthcare

Instructor Name

March 12, 2026

What this page is doingThe title names the measure by its steward's identifier, not by a general topic such as blood pressure control. Reading the specification is the first step in this analysis, and naming the exact measure commits the paper to it.

Controlling High Blood Pressure (CMS165): A Gap Analysis for a Four-Clinician Primary Care Practice

The Measure

This analysis examines Controlling High Blood Pressure, electronic clinical quality measure CMS165, a measure the Centers for Medicare & Medicaid Services keeps and uses in federal reporting programs and many payer contracts (Centers for Medicare & Medicaid Services [CMS], 2023). The version reviewed is the one in effect for the 2024 measurement period. The practice studied is a composite suburban primary care office with two physicians and two nurse practitioners.

The Specification, Read Before the Data

Denominator: patients aged 18 to 85 with a diagnosis of essential hypertension that starts before and continues into, or starts during, the first six months of the measurement period, and who had a qualifying visit during the period. Numerator: patients whose most recent blood pressure in the measurement period is adequately controlled, meaning systolic below 140 and diastolic below 90 mm Hg. When more than one reading is taken on the most recent date, the lowest systolic and lowest diastolic from that date are used. Readings taken during an acute inpatient stay or an emergency department visit do not count. Exclusions: patients in hospice or receiving palliative care; patients with end-stage renal disease, dialysis, or a kidney transplant; pregnancy; and specified older adults with frailty and advanced illness or living long term in institutions (CMS, 2023). Measurement period: the calendar year.

Three features of this specification matter more than the rest for this practice. First, only the most recent reading counts, so a well-controlled patient whose last reading of the year was taken during an acute illness fails the measure. Second, the lowest reading on the date counts, so a repeat reading taken but never entered in a structured field is lost. Third, exclusions only apply if they are coded; a patient in hospice care whose status sits in a scanned letter remains in the denominator.

What this page is doingThe specification is stated before any performance number, as the steward defines it. A great many apparent gaps turn out to be patients who should have been excluded or care documented outside the field the measure reads, and an analysis that skips this step aims its recommendations at patients the measure never counted.

Current Performance

For the 2024 measurement period, the practice's electronic health record report shows 1,240 patients in the denominator and 818 in the numerator, a rate of 66.0%. The comparison that makes this meaningful is twofold: the practice's own rate for 2023 was 63.4%, so it has improved slightly, and the health system's network dashboard lists a median of 71.5% across its 22 primary care practices and a contract target of 75%. The practice is behind its network and below its target by about 110 patients.

The Gap

Four hundred twenty-two patients fell outside the numerator. Because examining every chart is not practical, a random sample of 60 of the 422 was reviewed by two reviewers using a structured form, with disagreements settled by discussion. For each chart, the reviewer asked three questions in order: does this patient belong in the denominator at all; if so, was the blood pressure truly uncontrolled at the end of the year; and if it was controlled, why did the measure not see it?

Causes, Separated and Counted

Denominator errors: 8 of 60 (13%). Five patients were enrolled in hospice or palliative care documented only in scanned outside records; two had end-stage renal disease on dialysis recorded in the problem list without the structured code the measure reads; one had moved out of state in February. These patients should not count and need coding, not care.

Documentation gaps: 21 of 60 (35%). In 13 charts, the first reading of the final visit was elevated, a repeat reading after rest was recorded in the free-text note as controlled, and the repeat never reached the vitals field. In 5 charts, the patient's final reading of the year came from a visit for acute pain or illness while a controlled reading from a chronic care visit weeks earlier was not the most recent. In 3 charts, controlled readings from a home monitoring program were in portal messages rather than in the record fields the measure accepts; whether each would qualify under the current rules on remote monitoring device readings was checked before counting them. Recommended measurement practice already calls for repeat readings after rest (Muntner et al., 2019); the practice does the repeat but loses it.

Care gaps: 31 of 60 (52%). In 19 charts, blood pressure was genuinely uncontrolled at the last visit and no treatment change or follow-up was documented. In 12 charts, the patient had no visit in the second half of the year, so the last reading was an old uncontrolled one or there was none.

Applied to all 422 patients, this split suggests roughly 55 denominator errors, 148 documentation gaps, and 219 care gaps. The sample of 60 is small, so these are estimates with wide uncertainty, but the pattern is clear enough to act on: about half of the gap is care, and about half is not.

What this page is doingThe analysis quantifies the split between care gaps, documentation gaps and denominator errors, with evidence for each, rather than asserting which dominates. Treating every gap as a care failure sends a practice into clinical redesign when part of the fix was a field nobody completed.

Interventions Against the Dominant Causes

Documentation first, because it is fastest and cheapest. A protocol for medical assistants: when a reading is 140/90 or above, repeat after five minutes of seated rest and enter both readings in the structured vitals field. Owner: the nurse manager, with a two-week training and weekly spot checks. A monthly coding review of patients with hospice, palliative care, or dialysis status flagged in scanned documents. Owner: the practice's quality coordinator.

Care second, because it is larger but slower. A registry list of patients whose last reading was uncontrolled, reviewed every two weeks by a registered nurse, with standing orders for a follow-up visit or a nurse blood pressure check within four weeks and a flag to the clinician for treatment intensification. Owner: the registered nurse care manager. Outreach by phone and text to patients with no visit in six months. This work applies the structure-process-outcome logic of quality improvement: the structural change, a registry and protocol, supports the process of follow-up that produces the outcome (Donabedian, 1988).

Confirming Improvement

The practice will track three numbers monthly on a run chart: the CMS165 rate, the proportion of elevated first readings with a structured repeat entered, and the proportion of uncontrolled patients with a follow-up within four weeks. Success would be a rate above 72% by the end of the next measurement period, with the documentation indicator above 90% within three months. The closing lesson from this analysis is that reading the specification moved roughly a third of the apparent gap out of the care column before any clinical change was proposed.

References

Centers for Medicare & Medicaid Services. (2023). Controlling high blood pressure (CMS165v12) [Electronic clinical quality measure specification, 2024 performance period]. eCQI Resource Center. https://ecqi.healthit.gov/ecqm/ec/2024/cms0165v12

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T., Jr. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087

Reading the NU 623 Unit 7 instructions

Unit 7 asks you to analyze performance on a clinical quality measure for a practice or population and identify why patients fall outside the target. Expect to describe the measure, including its specification: denominator, exclusions and numerator. Current performance should be compared with a benchmark. The core task is usually explaining the gap by separating its causes, such as documentation problems, data errors and real care gaps, ideally with chart review data. Many sections ask for interventions matched to the largest causes and a plan to measure improvement. Cite the measure steward's specification and evidence for the interventions in APA 7. Use a composite practice and invented data. Length follows your rubric; a cause table or run chart is required in some sections.

How the NU 623 Unit 7 example is put together

The analysis begins by naming the measure and its steward and explaining why the practice reports it. The specification section reads each element before any data appear, so the reader knows who counts and who is excluded. Current performance gives counts and a rate and compares them with a benchmark. The gap section explains the sampling method, 60 charts reviewed by two people with a structured tool. Causes are then separated and counted: denominator errors such as hospice patients documented only in scanned records, documentation gaps where a repeat reading was taken but not entered, and true care gaps where blood pressure was uncontrolled. Interventions match the causes, starting with the cheapest and fastest documentation fix and moving to treatment intensification. The final section defines three numbers for a monthly run chart.

Where the points sit in the NU 623 Unit 7 rubric

Herzing rubrics for a gap analysis usually reward understanding of the measure, data presentation, analysis of causes, interventions, evaluation plan and writing. Measure points require a correct, cited description of the specification. Data presentation is credited when counts and rates are clear and compared with a benchmark. The causes criterion usually weighs most, and markers want causes separated into types and supported by review data instead of assumptions. Intervention points go to actions matched to the largest causes and grounded in evidence. Evaluation is scored on specific measures tracked over time, such as a run chart. Writing points cover organization, accurate numbers that add up and APA citations for the specification, measurement guidance and quality improvement sources.

Common NU 623 Unit 7 mistakes, and how to avoid them

Gap analyses commonly lose points by assuming every patient outside the numerator has uncontrolled blood pressure, when many gaps are documentation or data problems. Students also skip the specification and misread who belongs in the denominator. Numbers that do not add up, or percentages without counts, cost accuracy points. Interventions are often generic, such as staff education, without being linked to a specific cause. Another frequent gap is missing a method for confirming improvement. Some papers propose an intervention for every possible cause and run out of space to explain any of them. Finally, cite the current year's specification, since measure details change and an outdated version may define the denominator differently.

Get a NU 623 Unit 7 example written to your instructions

Send the Unit 7 instructions and the rubric from your NU 623 classroom, plus the measure and whatever performance data you can share. We write a custom example that reads the specification, splits the causes and aims the intervention at the dominant one, returned in 24 to 48 hours. The first custom sample is free.

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NU 623 Unit 7 questions, answered

Why read the specification so carefully?

Because a large share of apparent gaps are specification issues. Patients who met an exclusion, care delivered a week outside the measurement window, or a service recorded in a field the measure does not read all appear as failures. Reading numerator, denominator and exclusions before analyzing anything routinely removes a third of the gap and redirects the rest.

How do I tell a documentation gap from a care gap?

Sample the charts. Pull a set of patients counted as failures and read what actually happened. If the care was delivered and recorded somewhere the measure does not look, you have a documentation problem with a quick fix. If it was not delivered, you have a clinical workflow problem. Guessing between them is the most expensive mistake available here.

Should I propose interventions for every cause?

Aim at whichever dominates. Practices have limited improvement capacity, and spreading it across three causes usually moves none of them. Quantify the split, choose the largest, and say what you would do about the others once the first is addressed. A focused intervention with an owner beats a comprehensive plan nobody executes.

Where can I find a free NU 623 Unit 7 sample paper?

This page carries the full NU 623 Unit 7 CMS165 gap analysis free, including the specification, chart review, counted causes, interventions and run chart plan. If your assignment uses a different quality measure, request a custom analysis at no charge; it is usually back within 48 hours.