2507 lines
94 KiB
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2507 lines
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<a href="/about-quality/MMS-overview">
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<span>MMS Overview</span>
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</a>
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</li>
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</ul>
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</div>
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<div class="desktop:grid-col-3">
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<div class="usa-nav__headermenu-item">
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<span><strong>New to Measures</strong></span>
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<ul id="basic-nav-section-New-to-Measures" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-New-to-Measures" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/new-to-measures/what-is-a-measure">
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<span>Get Started with Quality Measures</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/new-to-measures/roles">
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<span>Roles in Measure Development</span>
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</a>
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</li>
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</ul>
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</div>
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<div class="desktop:grid-col-3">
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<div class="usa-nav__headermenu-item">
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<span><strong>Types of Measures</strong></span>
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<ul id="basic-nav-section-Types-of-Measures" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Types-of-Measures" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/types/overview">
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<span>Overview</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_expanded">
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<span>Composite Measure</span>
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</button>
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<ul id="basic-nav-section-Composite-Measure" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Composite-Measure" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/types/composite-measure/overview">
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<span>Overview</span>
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</a>
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||
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/types/composite-measure/component-measures">
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<span>Component Measures</span>
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</a>
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||
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||
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</li>
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</ul>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/types/population-health">
|
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<span>Population Health Measures</span>
|
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</a>
|
||
|
||
|
||
</li>
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||
|
||
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||
</ul>
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||
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</div>
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<div class="desktop:grid-col-3">
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<div class="usa-nav__headermenu-item">
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<span><strong>Quality Measurement at CMS</strong></span>
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</div>
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<ul id="basic-nav-section-Quality-Measurement-at-CMS" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Quality-Measurement-at-CMS" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/quality-at-CMS/goals">
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<span>CMS Goals and Priorities</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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||
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<a href="/about-quality/quality-at-CMS/principles">
|
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<span>Measure Development Principles</span>
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</a>
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</li>
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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<a href="/about-quality/quality-at-CMS/quality">
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<span>Quality Across CMS</span>
|
||
</a>
|
||
|
||
|
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</li>
|
||
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||
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</ul>
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</div>
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</div>
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</div>
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</li>
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<li class="usa-nav__primary-item is_expanded">
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<button id="usa-accordion__button" class="usa-accordion__button usa-nav__link usa-current is_expanded " aria-expanded="false" aria-controls="extended-mega-nav-section-2">
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<span>Blueprint Measure Lifecycle</span>
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</button>
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<div class="grid-row grid-gap-3 gridused">
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<div class="desktop:grid-col-3">
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|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Blueprint Measure Lifecycle</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Blueprint-Measure-Lifecycle" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Blueprint-Measure-Lifecycle" >
|
||
|
||
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||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/blueprint-measure-lifecycle-overview">
|
||
<span>Blueprint Measure Lifecycle Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/about-quality/blueprint-measure-lifecycle/theory">
|
||
<span>Measure Development Theory</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Conceptualization</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Conceptualization" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Conceptualization" >
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||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
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||
|
||
|
||
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||
<button id="usa-accordion__button_second-2 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Conceptualization">
|
||
<span>Information Gathering</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Information-Gathering" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Information-Gathering" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
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||
|
||
|
||
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||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/conduct-environment-scan">
|
||
<span>Conduct an Environmental Scan</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/analyze-data-gap-analysis">
|
||
<span>Analyze Data & Conduct Gap Analysis</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/respecified-measures">
|
||
<span>Respecified Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/information-gathering/justify-creation-new-measures">
|
||
<span>Justify the Creation of New Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-2 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Conceptualization">
|
||
<span>Business Case Development</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Business-Case-Development" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Business-Case-Development" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/outcomes">
|
||
<span>Documenting Outcomes, Benefits, & Costs</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-conceptualization/business-case/best-practices">
|
||
<span>Business Case Best Practices</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Specification</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Specification" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Specification" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specifications-measure-category">
|
||
<span>Specifications by Measure Category</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/define-data-sources">
|
||
<span>Define Data Sources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Develop Specifications</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Develop-Specifications" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Develop-Specifications" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/target-initial-population">
|
||
<span>Define the Target/Initial Population</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/denominator">
|
||
<span>Define the Denominator</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/numerator">
|
||
<span>Define the Numerator and Exclusions</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/stratification">
|
||
<span>Define Stratification Scheme</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/develop-specification/respecifying-registry-measures">
|
||
<span>Respecifying Registry Measures to Electronic Clinical Quality Measures (eCQMs)</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Specify the Code</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Specify-the-Code" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Specify-the-Code" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/code-systems-vocabularies-terminologies">
|
||
<span>Code Systems, Vocabularies, and Terminologies</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/encode-clinical-information">
|
||
<span>Encoding Clinical Information</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/specify-code/data-standards">
|
||
<span>Data Standards</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Construct Data Protocol</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Construct-Data-Protocol" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Construct-Data-Protocol" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/key-terms">
|
||
<span>Define Key Terms, Data Elements, Codes, and Code Systems</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/level-measurement-analysis">
|
||
<span>Describe Level of Measurement & Sampling</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/risk-adjustment">
|
||
<span>Determine Risk Adjustment</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/time-interval">
|
||
<span>Define Any Time Intervals</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/data-protocol/scoring">
|
||
<span>Describe Scoring & Calculation Algorithm</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/document-measure">
|
||
<span>Document the Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-3 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Specification">
|
||
<span>Measure Harmonization</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Harmonization" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Harmonization" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/alignment">
|
||
<span>Measure Harmonization and Alignment</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-specification/measure-harmonization/when-to-consider">
|
||
<span>When to Consider Measure Harmonization</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Testing</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Testing" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Testing" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-4 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Testing">
|
||
<span>Measure Testing Process</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Testing-Process" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Testing-Process" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/develop-workplan">
|
||
<span>Develop The Testing Work Plan</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/perform-sampl">
|
||
<span>Perform Sampling</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/implement-and-analyze">
|
||
<span>Implement, Analyze, Refine & Retest</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/summary">
|
||
<span>Measure Testing Summary</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/process/testing-respecified-measures">
|
||
<span>Testing Respecified Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
||
<button id="usa-accordion__button_second-4 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Testing">
|
||
<span>Measure Evaluation Criteria</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Evaluation-Criteria" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Evaluation-Criteria" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/importance">
|
||
<span>Importance</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability">
|
||
<span>Scientific Acceptability</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/feasibility">
|
||
<span>Feasibility</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-testing/evaluation-criteria/usability">
|
||
<span>Usability & Use</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Implementation</strong></span>
|
||
</div>
|
||
|
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|
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|
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|
||
<ul id="basic-nav-section-Measure-Implementation" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Implementation" >
|
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|
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|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
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|
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|
||
|
||
<a href="/measure-lifecycle/measure-implementation/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/selection">
|
||
<span>Measure Selection</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_expanded">
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<span>Pre-Rulemaking</span>
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</button>
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<ul id="basic-nav-section-Pre-Rulemaking" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Pre-Rulemaking" >
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
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|
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|
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|
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<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/overview">
|
||
<span>Overview</span>
|
||
</a>
|
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|
||
|
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</li>
|
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|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/guidance-measure-submitters">
|
||
<span>Guidance for Measure Submitters</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/measure-priorities">
|
||
<span>Measure Priorities</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/lists-and-reports">
|
||
<span>MUC Lists and Recommendation Reports</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/rollout">
|
||
<span>Measure Rollout</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
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|
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<button id="usa-accordion__button_second-5 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Implementation">
|
||
<span>CMS Consensus-Based Entity (CBE) Endorsement and Maintenance</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-CMS-Consensus-Based-Entity-(CBE)-Endorsement-and-Maintenance" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-CMS-Consensus-Based-Entity-(CBE)-Endorsement-and-Maintenance" >
|
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|
||
|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/Measure-Submission-to-the-CMS-CBE">
|
||
<span>Measure Submission to the CMS CBE</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/Endorsement-Process">
|
||
<span>The CMS CBE Endorsement Process</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Measure Use, Continuing Evaluation & Maintenance</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/production-and-monitoring">
|
||
<span>Measure Production & Monitoring</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/evaluation">
|
||
<span>Continuing Evaluation</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
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|
||
|
||
|
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<button id="usa-accordion__button_second-6 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link usa-currentis_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Measure-Use,-Continuing-Evaluation-&-Maintenance">
|
||
<span>Measure Maintenance Reviews</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Measure-Maintenance-Reviews" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Measure-Maintenance-Reviews" >
|
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|
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|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/annual-update">
|
||
<span>Annual Update</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/comprehensive-reevaluation">
|
||
<span>Comprehensive Reevaluation</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/early-maintenance-review">
|
||
<span>Early Maintenance Review</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-use/maintenance/harmonization-during-maintenance">
|
||
<span>Harmonization during Measure Maintenance</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Interested Party Engagement</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Interested-Party-Engagement" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Interested-Party-Engagement" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/lifecycle">
|
||
<span>Interested Party Engagement in the Measure Lifecycle</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/roles">
|
||
<span>Roles in Engagement</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/stakeholder-engagement/types">
|
||
<span>Types of Interested Party Engagement</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__primary-item is_expanded">
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<button id="usa-accordion__button" class="usa-accordion__button usa-nav__link is_expanded " aria-expanded="false" aria-controls="extended-mega-nav-section-3">
|
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<span>Tools & Resources</span>
|
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</button>
|
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|
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|
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<div id="extended-mega-nav-section-3" class="usa-nav__submenu usa-megamenu" hidden="">
|
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<div class="grid-row grid-gap-3 gridused">
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||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>MMS Tools & Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-MMS-Tools-&-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-MMS-Tools-&-Resources" >
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/tools-and-resources/mms-supplemental-materials">
|
||
<span>Supplemental Materials</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/tools-and-resources/mms-templates">
|
||
<span>Templates for Measure Development</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
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<a href="/educational-resources">
|
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<span>Educational Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/mms-tools">
|
||
<span>MMS Tools</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Additional Tools & Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Additional-Tools-&-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Additional-Tools-&-Resources" >
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/cms-tools">
|
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<span>CMS Tools</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/external-resources">
|
||
<span>External Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="https://mmshub.cms.gov/glossary">
|
||
<span>Glossary</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Pre-Rulemaking Resources</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Pre-Rulemaking-Resources" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Pre-Rulemaking-Resources" >
|
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|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/Pre-Rulemaking-Resources">
|
||
<span>Pre-Rulemaking Resources</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__primary-item is_expanded">
|
||
|
||
<button id="usa-accordion__button" class="usa-accordion__button usa-nav__link is_expanded " aria-expanded="false" aria-controls="extended-mega-nav-section-4">
|
||
<span>Get Involved</span>
|
||
</button>
|
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|
||
|
||
|
||
<div id="extended-mega-nav-section-4" class="usa-nav__submenu usa-megamenu" hidden="">
|
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|
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|
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<div class="grid-row grid-gap-3 gridused">
|
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|
||
|
||
<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Get Involved</strong></span>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Get-Involved" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Get-Involved" >
|
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|
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|
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/get-involved/how-to">
|
||
<span>How to Get Involved</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_expanded">
|
||
|
||
|
||
|
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<button id="usa-accordion__button_second-1 usa-nav__submenu-list-2" class="usa-accordion__button_second usa-nav__link is_expanded closed" aria-expanded="false" aria-controls="basic-nav-section-Get-Involved">
|
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<span>Technical Expert Panels</span>
|
||
</button>
|
||
|
||
|
||
|
||
<ul id="basic-nav-section-Technical-Expert-Panels" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-Technical-Expert-Panels" >
|
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|
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|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/get-involved/technical-expert-panel/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
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<div property="schema:text" class="field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>During <abbr tabindex="0" title="<p><span class="glossify-exclude">Measure maintenance</span> is the periodic and consistent reviewing, evaluating, and updating of performance measures to ensure continued reliability, validity, feasibility, importance, usability, and currency with science. It also involves comparison to similar measures for potential harmonization.</p> " class="glossify-tooltip-tip" lang="en">measure maintenance</abbr>, it is important that measure developers analyze measure performance trends, including feedback through help desks and trainings, to determine whether the measure undergoing reevaluation is still the best or most relevant measure, and whether the measure developer needs to address any unintended consequences.</p><p>After implementation of measures, the measure developer monitors measures’ performance, addresses ongoing feedback, and continuously scans the environment regarding the measures. For example, for <abbr tabindex="0" title="<p>An electronic clinical quality measure (eCQM) is a measure specified in a standard electronic format that uses data electronically extracted from electronic health records and/or health information technology systems to measure the quality of health care provided. Electronic Clinical Quality Improvement Resource Center. (n.d.) <em>Glossary</em>. Retrieved May 22, 2024, from&nbsp;https://ecqi.healthit.gov/glossary</p>" class="glossify-tooltip-tip" lang="en">electronic clinical quality measures</abbr>, the <a href="https://oncprojectracking.healthit.gov/">ONC Project Tracking System (Jira)</a> is one method for collecting and monitoring feedback on measure implementation.</p><p>In addition, two measure maintenance activities apply to every measure: annual update and a triennial comprehensive reevaluation. A third activity, the early maintenance review, occurs only if there are significant unforeseen problems with the measure, such as a major change in the measure’s scientific evidence base.</p><h3>Outcomes</h3><p>CMS uses one of five outcomes following maintenance review of CMS measures. However, some programs may have different terminology, outcomes, and <abbr tabindex="0" title="<p>A criterion is an accepted standard, principle, or rule used to make a decision or to inform an evaluator’s judgment.</p> " class="glossify-tooltip-tip" lang="en">criteria</abbr>. </p><dl class="ckeditor-accordion"><dt>Retain or Revise</dt><dd><p>Retain - Keep the measure active with its current <abbr tabindex="0" title="<p><span class="glossify-exclude">Specifications</span> are measure instructions addressing data elements, data sources, point of data collection, timing and frequency of data collection and reporting, specific instruments used (if appropriate), and implementation strategies.</p> " class="glossify-tooltip-tip" lang="en">specifications</abbr> and <abbr tabindex="0" title="<p>A <span class="glossify-exclude">minor change</span> does not change the process of data collection, aggregation, or calculation, nor does it change the intended meaning of the measure or the strength of the measure in terms of the measure evaluation criteria. For example, the code system updates to eCQMs with the Annual Update are <span class="glossify-exclude">minor changes</span>.</p> " class="glossify-tooltip-tip" lang="en">minor changes</abbr>. Revise - Update the measure’s current specifications to reflect new information.</p><p><strong>Criteria to Retain or Revise</strong> </p><ul><li>Measure is responsive to specific program goals and statutory requirements.</li><li>Measure addresses an important condition/topic with a performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more affordable care.</li><li>Measure addresses one or more of the CMS Quality Priorities.</li><li>Measure selection promotes <abbr tabindex="0" title="<p>Alignment, with respect to quality measures, is encouraging the use of similar, standardized quality measures across and within public and private sector efforts. Achievement of alignment is when a set of measures works well across care settings or programs to produce meaningful information without creating extra work for measured entities. Alignment includes using the same quality measures in multiple programs when possible. It can also come from consistently measuring important topics across care settings.</p> " class="glossify-tooltip-tip" lang="en">alignment</abbr> with CMS program attributes and across Department of Health and Human Services (HHS) programs.</li><li>Measure developers have <abbr tabindex="0" title="<p>To meet these selection criteria, the measure developer must complete&nbsp; testing of the measure. This means the measure developer has completed&nbsp;</p><ul><li>Person/encounter-level (data element-level) reliability and validity testing, when appropriate,&nbsp;for each&nbsp;critical data element&nbsp;and the measure&nbsp;specifications&nbsp;do not need changes based on the results.&nbsp;Testing may be empiric or reference external or previous testing (e.g., established data element library such as the CMS&nbsp;<a href="https://del.cms.gov/DELWeb/pubHome">Data Element Library&nbsp;(DEL)</a> or <a href="https://ecqi.healthit.gov/mc-workspace-2/data-element-repository">Data Element Repository (DERep)</a> or literature).</li></ul><p>AND</p><ul><li>Accountable entity-level (measure score-level) reliability and validity testing, when appropriate, and specifications do not need changes based on the results. Measure developers are encouraged to report accountable entity-level reliability results by decile (rather than just the median) to detect differences in reliability across the target population size distribution.</li><li>Completion of face&nbsp;<a href="https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/validity">validity testing</a>&nbsp;as the sole type of&nbsp;validity&nbsp;testing does not meet the criteria for completion of testing for a fully developed measure. However,&nbsp;face validity&nbsp;is acceptable for new measures (i.e., those not currently in use in CMS programs and undergoing substantive changes) that are not electronic Clinical Quality Measure (eCQM)&nbsp;.&nbsp;Instead of Likert-scale type assessments of face validity, measure developers are encouraged to develop a logic model consisting of inputs, activities, outputs, and outcomes to describe the associations between the health care structures and processes and the desired health outcome(s). The logic model should indicate the structure(s), process(es), and/or outcome(s) included in the measure. A detailed logic model will help the measure developer identify appropriate constructs for future empiric validity testing.</li></ul><p>AND</p><p>For measures based on survey data or patient-reported assessment tools, including&nbsp;patient-reported outcome-based performance measures&nbsp;(PRO-PMs), the measure developer has tested reliability and validity of the survey or tool and the survey or tool does not need changes based on the results. For measures based on assessment tools, the measure developer must have completed reliability and validity testing for each critical data element and complete testing of the assessment tool itself with no changes to the tool needed based on the results.</p>" class="glossify-tooltip-tip" lang="en">fully developed</abbr> the measure, including the completion of testing.</li><li>Measure reporting is feasible.</li><li>Measure results and performance should identify <abbr tabindex="0" title="<p>Opportunity for improvement is when data demonstrate considerable variation or overall, less-than-optimal performance, in the quality of care across measured entities, and/or there are disparities in care across population groups.</p> " class="glossify-tooltip-tip" lang="en">opportunities for improvement</abbr>. CMS will not select <abbr tabindex="0" title="<p><span class="glossify-exclude">Topped-out</span>, sometimes referred to as <span class="glossify-exclude">topped off</span>, is when measure’s performance is so high and unvarying that measured entities can no longer make meaningful distinctions and improvements in performance.</p> " class="glossify-tooltip-tip" lang="en">topped out</abbr> measures.</li><li>Use of the measure in a program does not result in negative unintended consequences (e.g., inappropriate reduced lengths of stay, overuse or inappropriate use of care or treatment, limiting access to care).</li><li>eCQMs must be fully developed and tested, entered in the <a href="https://www.emeasuretool.cms.gov/madie-mvp">Measure Authoring Development Integrated Environment (MADiE)</a> and created in <a href="https://ecqi.healthit.gov/hqmf">Health Quality Measure Format</a> using the <a href="https://ecqi.healthit.gov/qdm">Quality Data Model (QDM)</a> and <a href="https://ecqi.healthit.gov/cql">Clinical Quality Language (CQL)</a>. eCQMs must pass <abbr tabindex="0" title="<p><span class="glossify-exclude">Feasibility criteria</span> is the extent to which the specifications, including measure logic, require data that are readily available or easily captured without undue burden and implemented for performance measurement.</p> " class="glossify-tooltip-tip" lang="en">feasibility</abbr> testing.</li><li>eCQMs must undergo <abbr tabindex="0" title="<p><span class="glossify-exclude">Reliability</span> reflects the measure is well defined and precisely specified so measured entities can implement consistently within and across organizations and that it distinguishes differences in performance.</p> " class="glossify-tooltip-tip" lang="en">reliability</abbr> and <abbr tabindex="0" title="<p><span class="glossify-exclude">Validity</span> includes measure <span class="glossify-exclude">validity</span> (when the measure accurately represents the evaluated concept and achieves the intended purpose, meaning to measure quality) and data element <span class="glossify-exclude">validity</span>, which is the extent to which the information represented by the data element or code used in the measure reflects the actual concept or event intended.</p> " class="glossify-tooltip-tip" lang="en">validity</abbr> testing, including review of the <abbr tabindex="0" title="<p><span class="glossify-exclude">Logic</span> is the criteria used to define a quality measure and its key components.</p> " class="glossify-tooltip-tip" lang="en">logic</abbr> and <abbr tabindex="0" title="<p>A <span class="glossify-exclude">value set</span> is a subset of concepts drawn from one or more code systems, where the concepts included in the subset share a common scope of use (e.g., Anticoagulant Therapy).</p> " class="glossify-tooltip-tip" lang="en">value sets</abbr> by the CMS partners.</li><li>Electronically specified whenever possible.</li></ul></dd><dt>Retire</dt><dd><p>Cease to collect or report the measure indefinitely. This applies to measures not owned or maintained by any <abbr tabindex="0" title="<p>A measure steward is an individual or organization that owns a measure and is responsible for maintaining the measure. Measure stewards are often the same as measure developers, but not always. Measure stewards are also the ongoing point of contact for people interested in a given measure.</p> " class="glossify-tooltip-tip" lang="en">measure steward</abbr>. If it is necessary to retire a measure from a set, other replacement measures may be available to complement the remaining measures in the set.</p><p><strong>Criteria for Retirement </strong></p><ul><li>CMS owns the measure, but will no longer use or maintain the measure.</li><li>No longer adds value commensurate with the cost of data collection and reporting.</li><li>Performance or improvement on a measure does not result in better outcomes.</li><li>Collection or public reporting of a measure leads to negative unintended consequences other than patient harm.</li><li>Does not align with current clinical guidelines or practice.</li><li>Measure performance is so high and unvarying that CMS can no longer make meaningful distinctions and improvements in performance.</li><li>The availability of a better measure that is more<ul><li>Broadly applicable (across settings, <abbr tabindex="0" title="<p>The <span class="glossify-exclude">population</span> is the total group of people of interest for a quality measure, sometimes called the target/initial <span class="glossify-exclude">population</span>. The measure <span class="glossify-exclude">population</span> is a defined subset appropriate to the measure set not excluded from the individual measure.</p> " class="glossify-tooltip-tip" lang="en">populations</abbr>, or conditions)</li><li>Proximal in time to desired outcomes for the particular topic</li><li>Strongly associated with desired outcomes for the particular topic</li><li>Aligned with other CMS/HHS programs</li></ul></li></ul></dd><dt>Suspend</dt><dd><ul><li>Temporarily cease to report a measure. Data collection and submission may continue. </li></ul></dd><dt>Remove</dt><dd><p>A specific program set no longer includes a measure for one or more reasons. This does not imply that other payors/purchasers/programs should cease using the measure. If CMS is the measure steward and another CMS program continues to use the measure, CMS may continue to maintain the measure. If another entity is the steward, the other payors/purchasers/programs that may be using the measure are responsible for determining if the steward should continue to maintain the measure.</p><p><strong>Criteria for Removal </strong></p><ul><li>CMS no longer uses the measure in a specific CMS program. If CMS owns the measure, CMS may continue to maintain it even after removal.</li><li>If another entity owns the measure, other payers/purchasers/programs using the measure are responsible for determining if the owner is continuing to maintain the measure.</li><li>Collection or public reporting of a measure leads to negative unintended consequences other than patient harm.</li><li><abbr tabindex="0" title="<p><span class="glossify-exclude">Measured entities</span> are the front-line clinicians and their organizations, including health information technology, collecting quality measurement data. <span class="glossify-exclude">Measured entities</span> are the implementers of quality measures. The effect of quality measure data collection on clinician workflow can be negative. There may be effects on their payments, positive and negative, with respect to reporting and actual performance on quality measures. Because of these potential effects, <span class="glossify-exclude">measured entities</span> should be involved in all aspects of the Measure Lifecycle.</p> " class="glossify-tooltip-tip" lang="en">Measured entities</abbr> cannot report the measure as currently specified.</li><li>A measure does not align with current clinical measure performance or is so high and unvarying that CMS can no longer make meaningful distinctions and improvements in performance.</li><li>The availability of a better measure that is more<ul><li>Broadly applicable (across settings, populations, or conditions)</li><li>Proximal in time to desired outcomes for the particular topic</li><li>Strongly associated with desired outcomes for the particular topic</li><li>Aligned with other CMS/HHS programs</li></ul></li><li>Many CMS programs have proposed, updated, and finalized factors for removal in their respective rules. For example, the Inpatient Prospective Payment System finalized eight factors for measure removal at FY 2019 IPPS/ LTCH PPS final rule (83 FR 41540 through 41544).<ul><li>Factor 1. Measure performance among hospitals is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made (that is, ‘‘topped-out’’ measures): Statistically indistinguishable performance at the 75th and 90th percentiles; and truncated coefficient of variation ≤0.10.</li><li>Factor 2. A measure does not align with the current clinical guidelines or practice.<br>Factor 3. The availability of a more broadly applicable measure (across settings, populations, or the availability of a measure that is more proximal in time to desired patient outcomes for the particular topic).</li><li>Factor 4. Performance or improvement on a measure does not result in better patient outcomes. </li><li>Factor 5. 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