How an Idea Becomes a Measure

How an Idea Becomes a Measure

Quality measures start as an idea or concept and are developed following a structured path outlined in the Blueprint. The steps below highlight how a measure evolves from an idea into a standard for measuring performance and improvement in healthcare.

  1. Identify and research an issue or need

The process starts when a healthcare issue or need is identified. This is part of the work conducted during the initial stage of the Measure Lifecycle, Measure Conceptualization. Anyone can identify an opportunity for improvement, including patients, caregivers, providers, researchers, associations, measure experts, or agencies. Once that need is recognized, a measure developer conducts an environmental scan. An environmental scan is research to determine if the issue or need is critical, whether it is already being investigated, and whether there is already a measure in place that could be used. The measure developer reviews published materials and talks with individuals and experts knowledgeable about the topic.

  1. Summarize the idea

After examination of all the materials and information, the measure developer continues Measure Conceptualization work by narrowing down the idea to something specific that they believe meets the identified need and will have a high impact on healthcare quality. The measure developer uses this material and information to write a brief summary and shares with stakeholders. Potential stakeholders include CMS and other policy makers, patients and caregivers, healthcare providers, and other groups.

  1. Consult stakeholders

Measure Conceptualization is also the time when the measure developer forms a Technical Expert Panel (TEP) to review the research and to provide insights. These experts include individuals and caregivers, clinicians, researchers, measure experts, and representatives of other impacted stakeholders. The measure developer may ask the public to share thoughts on the measure through a call for public comments. After weighing all the feedback received, the measure developer and TEP recommend if the idea should move forward as a measure.

  1. Outline the potential measure’s components; begin testing

If CMS makes the decision to move forward with the potential measure, the measure developer drafts the specifications. This stage is referred to as Measure Specification in the Measure Lifecycle. Specifications are the building blocks of the measure and the details about how those blocks are put together. The developer writes a description about the measurement topic and identifies who or what will be evaluated by the measure. The focus of the measure, such as target process, condition, event, or outcome, is also outlined. Measure developers also consider other factors during specification like whether some populations or events should be excluded from the measure or whether the measure needs to be adjusted statistically for fairer comparisons.

The proposed measure is then tested, updated to improve the measure, and tested again until the measure developer is satisfied, and the measure meets the evaluation criteria. The TEP also helps the measure developer review testing results and offers suggestions. These activities occur during the Measure Testing stage of the Measure Lifecyle.

  1. Submit potential measure for expert review

If submitted for approval to a national multi-stakeholder group such as the National Quality Forum (NQF), the group reviews the measure to see if it is scientifically sound, if there is a strong need for the measure, and if it addresses a critical gap. The group asks the public and interested stakeholders for comments. Once the group has finished its review and evaluated feedback, the stakeholder group decides whether to endorse the measure or to send it back to the measure developer with recommended improvements.

  1. Propose the measure for adoption

Once all the reviews on a potential measure are complete, the measure developer enters the Measure Implementation stage of the Measure Lifecycle. At this stage, CMS looks at the collected information and decides whether the measure fits into a program and if they want to adopt the measure. If CMS decides to adopt the measure, it moves forward for use within an appropriate CMS program. The measure may need to then go through the pre-rulemaking and rulemaking processes. If CMS decides not to adopt the measure, CMS informs the measure developer and interested stakeholders. The measure developer may decide to do additional work on the measure based on feedback and resubmit the measure later.

  1. Finalize the measure

Once the measure has been adopted into a CMS program, the measure developer creates an implementation plan. CMS and the measure developer inform impacted parties about the new measure, when it will be ready for use, and how to use it.

  1. Implement the measure

Continuing with Measure Implementation, healthcare providers start collecting the data required by the measure and reports the results to CMS. CMS uses the quality measure results in their quality programs. Healthcare providers use the data to support and facilitate healthcare decisions. This data informs the public about the quality of care provided.

  1. Review the measure regularly

As part of the Measure Use, Continuing Evaluation, and Maintenance stage of the Measure Lifecycle, the measure developer annually reviews the specifications used in the measure. Every three years, measure developers perform an in-depth evaluation on the measure to see if quality is improving and if the measure is still needed. There might be an earlier review needed—for example, if there are negative unintended consequences of the measure or if the science behind the measure changes and the current measure could cause harm. If CMS determines the measure is no longer needed, it will be removed from the CMS programs.


Page Last Modified:
12/01/2021 08:00 PM