Aligning Quality Measures Across CMS - the Universal Foundation

To further the goals of the CMS National Quality Strategy, CMS leaders from across the Agency have come together to streamline quality measures across CMS quality programs for the adult and pediatric populations. This “Universal Foundation” of quality measures will focus provider attention, reduce burden, identify disparities in care, prioritize development of interoperable, digital quality measures, allow for cross- comparisons across programs, and help identify measurement gaps. The development and implementation of the Preliminary Adult and Pediatric Universal Foundation Measures will promote the best, safest, and most equitable care for individuals as we all work together on these critical quality areas. As CMS moves forward with the Universal Foundation, we will be working to identify foundational measures in other specific settings and populations to support further measure alignment across CMS programs as applicable.

Selection Criteria for the Universal Foundation:

  • The measure is of a high national impact
  • The measure can be benchmarked nationally and globally
  • The measure is applicable to multiple populations and settings
  • The measure is appropriate for stratification to identify disparity gaps
  • The measure has scientific acceptability
  • The measure is feasible and computable (or capable of becoming digital)
  • The measure has no unintended consequences

These measures will be used across CMS quality programs and prioritized for stratification and digitization. The CMS Center for Medicare & Medicaid Innovation (CMMI) retains the role to test new and innovative measures.

Universal Foundation:

Adult
Domain Measure Identification Number and Name
Wellness and prevention 139: Colorectal cancer screening
93: Breast cancer screening
26: Adult immunization status 
Chronic conditions 167: Controlling high blood pressure
204: Hemoglobin A1c poor control (>9%)
Behavioral health 672: Screening for depression and follow-up plan
394: Initiation and engagement of substance use disorder treatment
Seamless care coordination 561 or 44: Plan all-cause readmissions or all-cause hospital readmissions
Person-centered care 158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)
Equity     Identification number undetermined: Screening for social drivers of health
Pediatric
Domain     Measure Identification Number and Name
Wellness and prevention 761 and 123: Well-child visits (well-child visits in the first 30 months of life; child and adolescent well-care visits)
124 and 363: Immunization (childhood immunization status; immunizations for adolescents)
760: Weight assessment and counseling for nutrition and physical activity for children and adolescents
897: Oral evaluation, dental services
Chronic conditions 80: Asthma medication ratio (reflects appropriate medication management of asthma) 
Behavioral health

672: Screening for depression and follow-up plan
268: Follow-up after hospitalization for mental illness
264: Follow-up after emergency department visit for substance use
743: Use of first-line psychosocial care for children and adolescents on antipsychotics 
271: Follow-up care for children prescribed attention deficit-hyperactivity disorder medicine 

Person-centered care 158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)

Add-ons:

Maternity Care add-on set and more sets to come in 2023. 

The Universal Foundation: Next Steps

The Universal Foundation will continue to evolve over time:

  • CMS will develop setting- and population-specific “add-on” measure sets
  • Measures may be replaced or removed when goals are met
  • Measures may be added to assess quality across the care journey
  • CMMI will continue to test new and innovative measures

CMS will solicit feedback on the Universal Foundation through comments, rulemaking, listening sessions, or other forums.

To learn more the impact and next steps of the Universal Foundation, read the recent publication of ‘Aligning Quality Measures Across CMS -the Universal Foundation’ in the New England Journal of Medicine.

Send feedback to QualityStrategy@cms.hhs.gov.

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Page Last Modified:
05/01/2023 11:19 AM