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Use, Continuing Evaluation, and Maintenance


Overview of the Measure Use, Continuing Evaluation and Maintenance Phase of Measure Development

Measure Use, Continuing Evaluation & Maintenance ensures that the measure continues to add value to quality reporting measurement programs and that its construction continues to be sound. Developers monitor and measure the use of quality measures to ensure that they continue to support the quality programs they were designed to support, and identify opportunities to tweak or repurpose measures to improve reporting and the increase the value of quality program measurement results. Measure use, continuing evaluation and maintenance tasks include:

  • Collect and review measure data for the various quality programs
  • Aggregate measure data and create reports
  • Assess impact, effectiveness, and efficiency
  • Publish measure reports and quality program assessments for public review
  • Evaluate reports and assessments to determine if any changes could be made to improve quality measure reporting or quality program results
  • Submit recommendations to CMS for consideration of new or revised quality measures or programs

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Once a measure is in use, data for the measure is collected, calculated, and publicly reported. The party responsible for the measure should continue environmental scans of the literature about the measure as new studies may be published that address the soundness of the measure. It is also important to monitor for unintended consequences the measure might have on clinical practice or outcomes.

The process of measure production and monitoring varies significantly from one measure set to another depending on factors, which may include, but are not limited to:

  • Scope of measure implementation.
  • Healthcare provider being measured.
  • Data collection processes.
  • Ultimate use of the measure (e.g., quality improvement, public reporting, pay-for-reporting, or value-based purchasing).
  • Program in which the measure is used.

Measure production and monitoring are reported via three basic types of measure maintenance reviews: annual updates, comprehensive reevaluations, and ad hoc reviews, with stakeholder inputs being a critical component of this review process. The primary steps for monitoring are:

  • Conduct data collection and ongoing surveillance
  • Respond to questions about the measure
  • Produce preliminary reports
  • Report measure results
  • Monitor and analyze the measure rates and audit findings
  • Perform measure maintenance or ad hoc review, when appropriate
  • Provide information that CMS can use in measure priorities planning

Resources:

Conduct Data Collection and Ongoing Surveillance:

CMS Blueprint (Section 3. In-Depth Topics – 26.1 Conduct Data Collection and Ongoing Surveillance)

NQF Measure Maintenance

Aggregate measure data and create reports:  

CMS Blueprint (Section 3. In-Depth Topics – 26.4 Report Measure Results)

Measure Reevaluation Type 1 – Measure Update:

CMS Blueprint (Section 3. In-Depth Topics – 27.1 Measure Update)

Conduct a thorough review of the measure:  

CMS Blueprint (Section 3. In-Depth Topics – 27.2 Comprehensive Reevaluation)

Conduct an Ad Hoc Review:

CMS Blueprint (Section 3. In-Depth Topics – 27.3 Ad Hoc Review)

 

Tools:

CMS Blueprint (Measure Information Form Instructions)

CMS Blueprint (Blank Measure Justification Form Template)

Final Phase

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