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<a href="/measure-lifecycle/measure-conceptualization/business-case/outcomes">
<span>Documenting Outcomes, Benefits, &amp; Costs</span>
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<a href="/measure-lifecycle/measure-specification/define-data-sources">
<span>Define Data Sources</span>
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<span>Overview</span>
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<a href="/measure-lifecycle/measure-specification/develop-specification/target-initial-population">
<span>Define the Target/Initial Population</span>
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<a href="/measure-lifecycle/measure-specification/develop-specification/denominator">
<span>Define the Denominator</span>
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<span>Define Stratification Scheme</span>
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<a href="/measure-lifecycle/measure-specification/develop-specification/respecifying-registry-measures">
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<span>Overview</span>
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<a href="/measure-lifecycle/measure-specification/specify-code/code-systems-vocabularies-terminologies">
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<span>Encoding Clinical Information</span>
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<a href="/measure-lifecycle/measure-specification/specify-code/data-standards">
<span>Data Standards</span>
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<span>Overview</span>
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<a href="/measure-lifecycle/measure-specification/data-protocol/key-terms">
<span>Define Key Terms, Data Elements, Codes, and Code Systems</span>
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<a href="/measure-lifecycle/measure-specification/data-protocol/level-measurement-analysis">
<span>Describe Level of Measurement &amp; Sampling</span>
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<a href="/measure-lifecycle/measure-specification/data-protocol/risk-adjustment">
<span>Determine Risk Adjustment</span>
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<a href="/measure-lifecycle/measure-specification/data-protocol/time-interval">
<span>Define Any Time Intervals</span>
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<a href="/measure-lifecycle/measure-specification/data-protocol/scoring">
<span>Describe Scoring &amp; Calculation Algorithm</span>
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<a href="/measure-lifecycle/measure-specification/document-measure">
<span>Document the Measures</span>
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<span>Measure Harmonization</span>
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<span>Overview</span>
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<a href="/measure-lifecycle/measure-specification/measure-harmonization/alignment">
<span>Measure Harmonization and Alignment</span>
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<a href="/measure-lifecycle/measure-specification/measure-harmonization/when-to-consider">
<span>When to Consider Measure Harmonization</span>
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<span>Interested Party Engagement in the Measure Lifecycle</span>
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<span><strong>Get Involved</strong></span>
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<span>Overview</span>
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<span>Updates to Established TEPs</span>
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<span>Overview</span>
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<span>Summaries of Past Public Comments</span>
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<span>Call for Measures</span>
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<div class="views-row"><div class="views-field views-field-field-parent-title"><h1 class="field-content"><span class="glossify-exclude">Measure <abbr tabindex="0" title="&lt;p&gt;&lt;span class=&quot;glossify-exclude&quot;&gt;Specifications&lt;/span&gt; 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.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">Specification</abbr></span></h1></div></div>
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<div property="schema:text" class="field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>The measure developer must complete the detailed technical <abbr tabindex="0" title="&lt;p&gt;&lt;span class=&quot;glossify-exclude&quot;&gt;Specifications&lt;/span&gt; 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.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">specifications</abbr>, including any additional documents required to evaluate and implement the measure as intended. There are CMS templates&nbsp;and several documents on the <abbr tabindex="0" title="&lt;p&gt;The Medicare Improvements for Patients and Providers Act of 2008 requires the U.S. Department of Health and Human Services to contract with a consensus-based entity (CBE) regarding performance measurement. The CMS CBE endorses quality measures through a transparent, consensus-based process incorporating feedback from diverse groups of interested parties to foster health care quality improvement.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">CMS consensus-based entity</abbr> (CBE) <a href="https://p4qm.org/SubmitaMeasure">Submit a Measure</a> page&nbsp;available to assist in documentation of specifications.</p><h3>Finalize the Measure Name and Description</h3><p>The measure name (or measure title) should be a very brief description of the measures focus and <abbr tabindex="0" title="&lt;p&gt;The &lt;span class=&quot;glossify-exclude&quot;&gt;target/initial population&lt;/span&gt; refers to all events for evaluation by a specific performance measure involving patients who share a common set of specified characteristics within a specific measurement set to which a given measure belongs. Measured entities should draw all patients/episodes (e.g., as numerator, as denominator) from the &lt;span class=&quot;glossify-exclude&quot;&gt;target/initial population&lt;/span&gt;.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">target/initial population</abbr>. If it is a CMS CBE-endorsed measure, use the CMS CBE-endorsed title. If not CMS CBE-endorsed, use the CMS Measures Inventory Tool (CMIT) title.</p><p><strong>Format: </strong>[target/initial population] who received/had [measure focus]</p><p><strong>Examples&nbsp;</strong></p><ul><li>Diabetes: Medical Attention for Nephropathy (<a href="https://cmit.cms.gov/cmit/#/FamilyView?familyId=206">CMIT Measure ID 206</a>)&nbsp;</li><li>Percent of Residents Whose Need for Help with Activities of Daily Living has Increased Long Stay&nbsp;(<a href="https://cmit.cms.gov/cmit/#/FamilyView?familyId=531">CMIT Measure ID 531</a>)</li></ul><p>For measures based on <abbr tabindex="0" title="&lt;p&gt;The appropriate use criteria are evidence-based standards to assist professionals who order and furnish applicable services to make the most appropriate treatment decisions for a specific clinical condition. See the&amp;nbsp;&lt;a href=&quot;https://www.cms.gov/medicare/quality/appropriate-use-criteria-program&quot;&gt;CMS Appropriate Use Criteria Program&lt;/a&gt;.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">appropriate use criteria</abbr>&nbsp;addressing overuse of certain services, there are three standardized title lead-ins.&nbsp;</p><ul><li>Appropriate Use of ...&nbsp;</li><li>Appropriate Non-Use of ...&nbsp;</li><li>Inappropriate Use of ... (for <abbr tabindex="0" title="&lt;p&gt;&lt;span class=&quot;glossify-exclude&quot;&gt;Inverse measures&lt;/span&gt; are measures where a lower performance rate is better. For example, the National Healthcare Safety Network calculates most healthcare-associated infections (HAIs) as a standardized infection ratio (SIR). The SIR compares the actual number of HAIs (i.e., the numerator) with the predicted number based on the baseline U.S. experience (e.g., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates. The goal is to have the numerator equal to or very close to zero, thereby, having a SIR equal to or very close to zero.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">inverse measures</abbr>—the least desirable approach)&nbsp;</li></ul><p>For the measure description, measure developers should briefly describe the type of <abbr tabindex="0" title="&lt;p&gt;The &lt;span class=&quot;glossify-exclude&quot;&gt;measure score&lt;/span&gt; is the numeric result computed by applying the measure specifications and scoring algorithm. The computed &lt;span class=&quot;glossify-exclude&quot;&gt;measure score&lt;/span&gt; represents an aggregation of all appropriate patient-level data (e.g., proportion of patients who died, average lab value attained) for the measured entity (e.g., hospital, health plan, home health agency, clinician). The measure specifications designate the measured entity and to whom the measure applies.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">score</abbr>&nbsp;(e.g., percentage, percentage rate, <abbr tabindex="0" title="&lt;p&gt;A &lt;span class=&quot;glossify-exclude&quot;&gt;proportion&lt;/span&gt; is a score derived by dividing the number of cases meeting a criterion for quality (i.e., the numerator) by the number of eligible cases within a given time frame (i.e., the denominator) where the numerator cases are a subset of the denominator cases (e.g., percentage of eligible women with a mammogram performed in the last year).&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">proportion</abbr>, number), target/initial population, and focus of measurement.</p><p><strong>Format:</strong> Patients in the target/initial population who received/had [measure focus] {during [time frame] if different than for target/initial population}</p><p>The measure description should consist of standardized phrases in a standard order.&nbsp;</p><ul><li>“The percentage of”&nbsp;</li><li>[sex qualifier] if applicable (e.g., “female”)</li><li>“patients or individuals”&nbsp;</li><li>“during visit or event”</li><li>[environment qualifier] (e.g., admitted to a post-anesthesia care unit [PACU])</li><li>[age qualifier] (e.g., aged 18 years and older)&nbsp;</li><li>[<abbr tabindex="0" title="&lt;p&gt;The &lt;span class=&quot;glossify-exclude&quot;&gt;denominator&lt;/span&gt; is a statement describing the population evaluated by the performance measure and is the lower part of a fraction used to calculate a rate, proportion, or ratio. It can be the same as the target/initial population or a subset of the target/initial population to further constrain the population for the purpose of the measure. CV measures may refer to this as measure population.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">denominator</abbr> definition] (e.g., who are under the care of an anesthesia practitioner)&nbsp;</li><li>[<abbr tabindex="0" title="&lt;p&gt;The &lt;span class=&quot;glossify-exclude&quot;&gt;numerator&lt;/span&gt; is the upper portion of a fraction used to calculate a rate, proportion, or ratio. Also called the measure focus, it is the target process, condition, event, or outcome. &lt;span class=&quot;glossify-exclude&quot;&gt;Numerator&lt;/span&gt; criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A &lt;span class=&quot;glossify-exclude&quot;&gt;numerator&lt;/span&gt; statement describes the action satisfying the conditions of the performance measure.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">numerator</abbr>&nbsp;<abbr tabindex="0" title="&lt;p&gt;A criterion is an accepted standard, principle, or rule used to make a decision or to inform an evaluators judgment.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">criteria</abbr>] (e.g., in which a formal post-anesthetic transfer of care protocol or checklist is used that includes key transfer of care elements)&nbsp;</li></ul><p>It is important to word <abbr tabindex="0" title="&lt;p&gt;The Patient Protection and Affordable Care Act defined a &lt;span class=&quot;glossify-exclude&quot;&gt;quality measure&lt;/span&gt; as “a standard for measuring the performance and improvement of population health or of health plans, providers of services, and other clinicians in the delivery of health care services.” (&lt;a href=&quot;https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf&quot;&gt;Pub. L. 111-148, 931&lt;/a&gt;)&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">quality measures</abbr>&nbsp;positively when possible (i.e., to demonstrate which activity to capture in the numerator).</p><p><strong>Examples&nbsp;</strong></p><ul><li>Percentage of patients 1875 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period (<a href="https://cmit.cms.gov/cmit/#/FamilyView?familyId=206">CMIT Measure&nbsp;ID&nbsp;206</a>).</li><li>Percentage of healthcare personnel who receive the influenza vaccination (<a href="https://cmit.cms.gov/cmit/#/FamilyView?familyId=390">CMIT Measure&nbsp;ID 390</a>) (<span>CMS CBE #</span>0431).</li><li>Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: a) percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks); b) percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) (<a href="https://cmit.cms.gov/cmit/#/FamilyView/?familyId=63">CMIT Measure ID 63</a>) (<span>CMS CBE #</span>0105).</li><li>Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access (<a href="https://cmit.cms.gov/cmit/#/FamilyView/?familyId=313">CMIT Member ID 313</a>) (<span>CMS CBE #</span>2978).</li></ul><h3>Making Changes</h3><p>Information from <abbr tabindex="0" title="&lt;p&gt;&lt;span class=&quot;glossify-exclude&quot;&gt;Measure testing&lt;/span&gt; is the empirical analysis to demonstrate the reliability and validity of the measure as specified, including analysis of issues posing threats to the validity of conclusions about quality of care such as exclusions, risk adjustment/stratification for outcome and resource use measures, methods to identify differences in performance, and comparability of data sources/methods.&lt;/p&gt; " class="glossify-tooltip-tip" lang="en">measure testing</abbr>, the public comment period, updated information gathering, or other interested party input may require the measure developer to make changes to technical specifications.&nbsp;</p></div>
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<div class="field field--name-field-body-cont- field--type-text-long field--label-hidden field__item"><dl class="ckeditor-accordion"><dt>Resources</dt><dd><p><a href="/sites/default/files/Blueprint-Measure-Information-and-Justification-Form-and-Instructions.docx" data-entity-type="media" data-entity-uuid="817e6a20-89c9-4fc1-82d3-f26976747c97" data-entity-substitution="media" title="Blueprint-Measure-Information-and-Justification-Form-and-Instructions.docx">Measure Information and Justification Form (MIJF) &amp; Instructions</a></p></dd></dl></div>
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