2479 lines
93 KiB
Text
2479 lines
93 KiB
Text
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<meta name="description" content="Measure production and monitoring includes the ongoing tasks necessary to use the measure over time. The graphic below provides an overview of the steps in the production and monitoring process. This process varies significantly from one measure set to another depending on a number of factors, which may include" />
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<title>Measure Production & Monitoring | The Measures Management System</title>
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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-1">
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<span>About Quality Measurement</span>
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<span><strong>About MMS</strong></span>
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<ul id="basic-nav-section-About-MMS" class="usa-nav__submenu-list-2 is_collapsed " aria-controls="extended-mmega-nav-section-About-MMS" >
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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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</div>
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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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</div>
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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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<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-Types-of-Measures">
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<span>Composite Measure</span>
|
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</button>
|
||
|
||
|
||
|
||
<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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||
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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/types/composite-measure/component-measures">
|
||
<span>Component Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</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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||
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||
<a href="/about-quality/types/population-health">
|
||
<span>Population Health Measures</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
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||
</div>
|
||
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||
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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>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<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">
|
||
<span>CMS Goals and Priorities</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
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||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/about-quality/quality-at-CMS/principles">
|
||
<span>Measure Development Principles</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<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="/about-quality/quality-at-CMS/quality">
|
||
<span>Quality Across CMS</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
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||
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||
</div>
|
||
</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">
|
||
<span>Blueprint Measure Lifecycle</span>
|
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</button>
|
||
|
||
|
||
|
||
<div id="extended-mega-nav-section-2" 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>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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||
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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" >
|
||
|
||
|
||
|
||
<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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||
|
||
|
||
|
||
<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" >
|
||
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<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 ">
|
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|
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|
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|
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<a href="/measure-lifecycle/measure-testing/evaluation-criteria/feasibility">
|
||
<span>Feasibility</span>
|
||
</a>
|
||
|
||
|
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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-testing/evaluation-criteria/usability">
|
||
<span>Usability & Use</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
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|
||
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</div>
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|
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<div class="desktop:grid-col-3">
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|
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<div class="usa-nav__headermenu-item">
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<span><strong>Measure Implementation</strong></span>
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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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<a href="/measure-lifecycle/measure-implementation/overview">
|
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<span>Overview</span>
|
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</a>
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|
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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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|
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<a href="/measure-lifecycle/measure-implementation/selection">
|
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<span>Measure Selection</span>
|
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</a>
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<span>Pre-Rulemaking</span>
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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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<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/overview">
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<span>Overview</span>
|
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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/guidance-measure-submitters">
|
||
<span>Guidance for Measure Submitters</span>
|
||
</a>
|
||
|
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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/pre-rulemaking/measure-priorities">
|
||
<span>Measure Priorities</span>
|
||
</a>
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|
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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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|
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|
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<a href="/measure-lifecycle/measure-implementation/pre-rulemaking/lists-and-reports">
|
||
<span>MUC Lists and Recommendation Reports</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
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|
||
|
||
|
||
</li>
|
||
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|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
||
<a href="/measure-lifecycle/measure-implementation/rollout">
|
||
<span>Measure Rollout</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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|
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<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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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
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<a href="/measure-lifecycle/measure-implementation/CMS-CBE-EM/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
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|
||
<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" >
|
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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/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>
|
||
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_expanded">
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<button id="usa-accordion__button_second-6 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-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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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
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|
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|
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<a href="/measure-lifecycle/measure-use/maintenance/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_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" >
|
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|
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<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
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|
||
<a href="/measure-lifecycle/stakeholder-engagement/overview">
|
||
<span>Overview</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
<li class="usa-nav__submenu-item menu_level_2 is_collapsed ">
|
||
|
||
|
||
|
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<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 ">
|
||
|
||
|
||
|
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<a href="/measure-lifecycle/stakeholder-engagement/types">
|
||
<span>Types of Interested Party Engagement</span>
|
||
</a>
|
||
|
||
|
||
</li>
|
||
|
||
|
||
</ul>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
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||
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||
|
||
|
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|
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</li>
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<span>Tools & Resources</span>
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<div class="desktop:grid-col-3">
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<div class="usa-nav__headermenu-item">
|
||
<span><strong>MMS Tools & Resources</strong></span>
|
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</div>
|
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|
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|
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|
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<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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|
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<a href="/tools-and-resources/mms-supplemental-materials">
|
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<span>Supplemental Materials</span>
|
||
</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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|
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|
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|
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<a href="/tools-and-resources/mms-templates">
|
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<span>Templates for Measure Development</span>
|
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</a>
|
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|
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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="/educational-resources">
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<span>Educational Resources</span>
|
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</a>
|
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|
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|
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</li>
|
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|
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|
||
<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>
|
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</div>
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|
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|
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|
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|
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<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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|
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|
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<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">
|
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<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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|
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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">
|
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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-4">
|
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<span>Get Involved</span>
|
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</button>
|
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|
||
|
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|
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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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<div class="grid-row grid-gap-3 gridused">
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|
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<div class="desktop:grid-col-3">
|
||
|
||
<div class="usa-nav__headermenu-item">
|
||
<span><strong>Get Involved</strong></span>
|
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</div>
|
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|
||
|
||
|
||
|
||
<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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<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>
|
||
|
||
|
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<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>
|
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</button>
|
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|
||
|
||
|
||
<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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<div class="views-row"><div class="views-field views-field-field-parent-title"><h1 class="field-content"><span class="glossify-exclude">Measure Use, Continuing Evaluation & Maintenance</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><span>Measure production and monitoring includes the ongoing tasks necessary to use the measure over time. The graphic below provides an overview of the steps in the production and monitoring process. This process varies significantly from one <abbr tabindex="0" title="<p>A measure set is a group of measures related in some way such as measures addressing a specific condition, procedure, or specialty.</p> " class="glossify-tooltip-tip" lang="en">measure set</abbr> to another depending on a number of factors, which may include</span></p><ul><li>Scope of measure implementation</li><li><span><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 entity</abbr></span></li><li><span>Data collection processes</span></li><li><span>Intended use of the measure (e.g., quality improvement, public reporting, pay-for-reporting, value-based purchasing)</span></li><li><span>Program measure use (measure evaluation <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">criterion</abbr>)</span></li></ul><p>The level of effort for each task may vary by different measure attributes. </p><p>There may be a requirement for measure developers to perform various tasks associated with ongoing implementation and production. The graphic provides an overview of the steps in the production and monitoring process.</p><p>Click image to enlarge. </p><div class="align-center">
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<a href="http://mmshub.cms.gov/sites/default/files/styles/max_1300x1300/public/2022-11/Measure%20Production%20and%20Monitoring.png?itok=ET1lVdvd" aria-controls="colorbox" aria-label="{"alt":"A flow chart of the measure production and monitoring processes."}" role="button" title="A flow chart of the measure production and monitoring processes." data-colorbox-gallery class="colorbox" data-cbox-img-attrs="{"alt":"A flow chart of the measure production and monitoring processes."}"><img src="/sites/default/files/styles/large/public/2022-11/Measure%20Production%20and%20Monitoring.png?itok=HrIZZ14D" width="600" height="331" alt="A flow chart of the measure production and monitoring processes." loading="lazy" typeof="foaf:Image">
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<h3>Conduct Data Collection and Ongoing Surveillance</h3><p><span>Once measure development is complete and there is resolution of <abbr tabindex="0" title="<p>A <span class="glossify-exclude">dry run</span> is full-scale measure testing involving all measured entities representing the full spectrum of the measured population. The purpose is to finalize all methodologies related to case identification/selection, data collection, and measurement calculation, and to quantify unintended consequences.</p> " class="glossify-tooltip-tip" lang="en">dry run</abbr> identified implementation issues (if applicable), the measure may go to full implementation where the measured entities collect and calculate data. The measure developer’s ongoing surveillance should include scanning medical and scientific publications as well as the general media for articles and commentaries about the measure.</span></p><p><span>Ongoing information surveillance is similar to the information gathering stage covered in </span><a href="/measure-lifecycle/measure-conceptualization/overview" data-entity-type="node" data-entity-uuid="357d3a68-7f4f-4923-875d-6090137c32ab" data-entity-substitution="canonical" title="Measure Conceptualization"><span>Measure Conceptualization</span></a><span>. The measure developer conducts analyses of the literature and submits or uses reports for annual measure updates, as required by the project. </span></p><p><span>As use of the measure continues, the measure developer identifies publication of new studies that address the soundness of the measure. The measure developer must pay attention to any organizations that issue relevant <abbr tabindex="0" title="<p>Clinical practice guidelines are systematically developed statements to support practitioner and patient decisions about appropriate health care for specific clinical circumstances.</p> " class="glossify-tooltip-tip" lang="en">clinical practice guidelines</abbr> (e.g., monitor </span><a href="https://www.ecri.org/solutions/ecri-guidelines-trust"><span>ECRI Guidelines Trust®</span></a><span>), especially for <abbr tabindex="0" title="<p>A process measure is a measure focusing on steps that should be followed to provide good care. There should be a scientific basis for believing that the process, when executed well, will increase the probability of achieving a desired outcome.</p> " class="glossify-tooltip-tip" lang="en">process measures</abbr>. If the measure is based on a specific set of guidelines, the measure developer should monitor the guidelines’ publisher closely for any indication of plans to change their guidelines. If the measure is not based on guidelines, the measure developer can monitor the scientific and clinical literature for reports that would impact the scientific basis of the measure. New information, guideline changes, or other statements may trigger an early maintenance review. </span></p><p><span>Measure developers can use the <abbr tabindex="0" title="<p>An environmental scan is the process of systematically reviewing and interpreting data to identify issues and opportunities that will influence prioritization of current or future plans.</p> " class="glossify-tooltip-tip" lang="en">Environmental Scan</abbr> Support Tool (</span><a href="https://cmit.cms.gov/cmit/#/EnvironmentalScan"><span>ESST</span></a><span class="MsoHyperlink">)</span><span> and <abbr tabindex="0" title="<p>A de novo measure is a new measure that is not based on an existing measure.</p> " class="glossify-tooltip-tip" lang="en">De Novo Measure</abbr> Scan (</span><a href="https://cmit.cms.gov/cmit/#/login"><span>DNMS</span></a><span>) (login required) to assist with the literature review. See the </span><a href="https://cmit.cms.gov/cmit/assets/EnvironmentalScan/ESST-Quick-Start-Guide-508.pdf"><span>ESST QuickStart Guide</span></a><span> f</span>or how to use the ESST. When you login to the DNMS, you will have access to the <a href="/sites/default/files/DNMS-Quick-Start-Guide.pdf" data-entity-type="media" data-entity-uuid="0174b81f-c730-4a4c-ba7d-72cbdb74c0c1" data-entity-substitution="media" title="De Novo Measure Scan (DNMS) Quick Start Guide"><span>DNMS QuickStart</span></a> and a tutorial video.</p></div>
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<div class="field field--name-field-body-cont- field--type-text-long field--label-hidden field__item"><p>After data collection begins, the measure developer monitors for unintended consequences the measure might have on clinical practice or outcomes. If the measure developer identifies significant unintended consequences in the literature or unusual trends in the data, especially if patient safety is the concern, they must not wait for a scheduled annual or comprehensive review, and an early maintenance review may be necessary.</p><h3>Respond to Questions About the Measure</h3><p><span>The measure developer may be responsible for reviewing interested party feedback and responding promptly, alerting the submitter of receipt and review of the feedback. Interested party feedback may include direct questions, help desk questions, comments about the measure, or the use of the measure in a specific program. Questions may offer ideas for education and outreach.</span></p><h3>Monitor and Analyze the Measure Rates and Audit Findings</h3><p><span>The measure developer should monitor and analyze measure performance rates and <abbr tabindex="0" title="<p>An audit is a systematic inspection of records or accounts to verify their accuracy.</p> " class="glossify-tooltip-tip" lang="en">audit</abbr> findings periodically. At a minimum, developers should perform annual assessments. </span></p><dl class="ckeditor-accordion"><dt>Annual Assessments</dt><dd><p>Annual assessments monitor and analyze for</p><ul><li>Overall performance trends</li><li>Variations in performance, gaps in care, and extent of improvement</li><li>Disparities in resulting rates by race, ethnicity, age, social risk factors, income, region, gender, primary language, disability, or other classifications</li><li>Frequency of use of <abbr tabindex="0" title="<p>The <span class="glossify-exclude">denominator</span> 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.</p> " class="glossify-tooltip-tip" lang="en">denominator</abbr> exclusions, <abbr tabindex="0" title="<p>The <span class="glossify-exclude">numerator</span> 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. <span class="glossify-exclude">Numerator</span> criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A <span class="glossify-exclude">numerator</span> statement describes the action satisfying the conditions of the performance measure.</p> " class="glossify-tooltip-tip" lang="en">numerator</abbr> exclusions, or denominator exceptions</li><li>Discretionary denominator/numerator exclusion, evaluate carefully for <abbr tabindex="0" title="<p><span class="glossify-exclude">Gaming</span> is when measured entities exploit weaknesses in the measurement system to tweak the data making their performance look better than it actually is. Includes limiting access to certain populations, neglecting care, or overuse of medications or services to ensure that the measure results are favorable.</p> " class="glossify-tooltip-tip" lang="en">gaming</abbr>, unintended consequences, and uneven application that could influence comparability</li><li>Patterns of errors in data collection or rate calculation</li><li>Changes in practice that may adversely affect rates Impact of measurement activities on <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></li><li>Correlation of the data to either confirm the measure’s efficacy or identify weaknesses in the measure</li></ul></dd></dl><p><span>Ongoing monitoring should continually assess a measure’s progression; any marked departures may be cause for concern. If the <abbr tabindex="0" title="<p>A <span class="glossify-exclude">business case</span> is a justification for a proposed project or undertaking on the basis of its expected commercial benefit. It exists if the entity realizes a financial return on its investment in a reasonable time frame. The entity may realize as profit, reduction in losses, or avoided costs. A <span class="glossify-exclude">business case</span> may also exist if the investor believes a positive indirect effect on organizational function and sustainability will accrue within a reasonable time frame (<a href="https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.22.2.17">Leatherman et al., 2003</a>). The <span class="glossify-exclude">business case</span> for a process measure relies on the financial return on the investment necessary to implement the intervention advocated by the measure. The <span class="glossify-exclude">business case</span> for other types of measures relies on the financial return resulting from improving the quality of care indicated by the measure.</p> " class="glossify-tooltip-tip" lang="en">business case</abbr> predicted performance targets, the measure developer should investigate any measure whose performance over time falls short of its target. Measure developers report this information during reevaluation.</span></p><h3>Perform Measure Maintenance or Early Maintenance Review, When Appropriate</h3><p>The measure developer should review each measure at least annually to ensure the codes used to identify the <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> (e.g., denominator, numerator, denominator and/or numerator exclusions) are current, and to address other needed <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>. Communicate all changes to interested parties. <a href="/measure-lifecycle/measure-use/maintenance/overview" data-entity-type="node" data-entity-uuid="a4c1074f-78a2-47d9-af3a-bd1432b1b769" data-entity-substitution="canonical" title="Measure Maintenance Reviews"><span>Measure Maintenance Reviews</span></a> describe the standardized processes for the annual update, the triennial full reevaluation, and early maintenance review.</p><p>If the <abbr tabindex="0" title="<p>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.</p> " class="glossify-tooltip-tip" lang="en">CMS consensus-based entity</abbr> (CBE) has endorsed the measure, the measure developer also reports the results of the maintenance review to the CMS CBE to reevaluate its endorsement at the time of CMS CBE maintenance review.</p></div>
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