How a Measure Becomes a Measure
How a Measure Becomes a Measure
How an idea becomes a quality measure
Quality measures are tools that help provide high-quality health care in a consistent, efficient, and accountable way. Measures start as an idea or concept and are developed by following a structured path, called the CMS Blueprint, that allows health care stakeholders to measure performance and improvement. Measures are developed and evaluated to align with evaluation criteria that assures the validity (accurately represents the concept) and reliability (well-defined) of the measure.
The process begins
The process starts with a patient, caregiver, provider, researcher, association, measure expert, or agency identifying a health care issue that has an opportunity for improvement and supports informed health care delivery and decision-making. Once that general need is recognized, an expert measure developer conducts an environmental scan, which is research to determine if it is a critical issue or need that should be addressed, whether it is already being looked at, and whether there is already a measure in place that could be used. The measure developer will look at what has been published and talk to individuals or experts who are knowledgeable about the topic.
The idea becomes a potential measure
After the developer has examined all the materials and information, they narrow the idea down to something specific that they believe will meet the identified need and that will have a high impact on health care quality. The developer uses this material and information to write up a brief synopsis about it and post it to share with stakeholders.
Experts weigh in
The developer forms a panel of experts to review what has been learned and to provide learned opinions. These experts include persons and caregivers, providers, researchers, measure experts and representatives of other impacted stakeholders. The developer may also ask the public to share thoughts on the measures through a call for public comments. After weighing all the feedback received, the measure developer and expert panel decide if the idea should move forward.
The measure is written and tested
If the decision is made to move forward on the potential measure, the developer drafts the specifications. Measure specifications include details about what is being addressed (numerator), what population of patients will be included (denominator), what population of patients should not be included and why (denominator exclusion), what the recommended actions are, and what results are anticipated. The proposed measure is then tested, changes are made as needed to improve it, and tested again until the developer is satisfied. The expert panel helps the developer review the results and makes suggestions. Once the developer and panel are satisfied with the results, the measure is submitted to a national group (such as the Measures Application Partnership) to review and provide input.
A national group reviews the measures that are submitted to see if the measures are scientifically sound, if there is a strong need for it, and if it addresses a critical gap. The group asks the public and interested stakeholders to weigh in again and provide feedback. Once the group has finished the review and evaluated the comments from the public and stakeholders, the national group makes a decision to endorse it or to send it back for more work to be done. Sometimes a need was already identified and Congress directed CMS to develop a specific type of measure to meet the need. In that case, CMS will ask for the public and interested stakeholders to provide feedback but it may not go through this second expert review.
The measure is accepted
Once all the reviews on a potential measure are complete, CMS will look at all the information that was collected and make a decision about whether the measure fits into a program and if they want to accept it. If the measure is accepted it will move forward to be used within an appropriate CMS program, which sometimes requires that it go through rulemaking. If they decide not to accept it, they inform the measure developer and interested stakeholders. The measure developer may decide to do additional work on the measure based on feedback and resubmit later.
The measure is finalized
Once the measure has completed rulemaking or has been accepted into a CMS program, an implementation plan is developed and they inform impacted parties about the new measure, when it will be ready for use, and how to use it.
The measure is implemented
When the implementation plan is carried out, health care providers start collecting the data required by the measure and provide the results to CMS. Results may be used in quality reporting programs or for compare sites, as well, to support and facilitate health care decisions. This data informs the public about the impact the measure had on quality care.
The measure is reviewed on a regular basis
At least once every three years, an evaluation is done on the measure to see if it is having the impact expected and if it is still needed. There might be earlier reviews or ad hoc reviews performed if there is a need—for example, if there are unexpected impacts due to unintended consequences of the measure. If a measure is still needed it continues to be used, if it is no longer needed it will be retired.