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Measure Implementation

The CMS CBE Endorsement Process

The CMS CBE follows a consensus-based process. Please view the E&M Guidebook, found on the PQM Endorsement & Maintenance (E&M) webpage, for more information on this process and for updates to timelines and approaches. Measure stewards/developers should monitor the PQM E&M webpage for new information, as the CMS CBE may periodically change their processes and timelines. For example, the CMS CBE does not require an annual review, but does require submission of a status report three years after endorsement. See the Submit a Measure webpage for the status report form. 

Measure Steward's/Developer's Role During the CMS CBE Evaluation

During the CMS CBE evaluation, measure stewards/developers 

  • Provide a factual review of the CMS CBE team’s preliminary measure assessment. 
  • Review public and committee comments on the measure submission. 
  • Attend the endorsement meeting to
    • Introduce the measure during opening remarks, which may address the comments submitted to the CMS CBE.
    • Provide context, rationale, and other insights.
    • Answer questions posed by committee members.

During its evaluation, the CMS CBE may suggest changes to the measure to make it more acceptable, to harmonize with other measures, or both. Learn more in the E&M Guidebook found on the PQM E&M webpage. 

Endorsed with Conditions

In some cases, the CMS CBE may grant an Endorsed with Conditions. The Endorsed with Conditions category serves as a means of endorsing a measure, but with conditions set by the endorsement committee. These conditions take into consideration what is feasible and appropriate for the measure steward/developer to execute by the time of maintenance endorsement review, which is typically set at 5 years. See the Maintenance of Endorsement section in the E&M Guidebook for more information. If the CMS CBE evaluates a measure with an Endorsed with Conditions designation for maintenance, but it has not met the prior conditions, then the committee may choose to remove endorsement, unless it agrees with any rationale provided by the measure steward/developer.

Measure Maintenance for Endorsement

Once the CMS CBE has endorsed a measure, the measure steward/developer supports ongoing maintenance of the measure endorsement if it is part of the scope of work for that measure steward/developer. The measure steward/developer is responsible for being familiar with the CMS CBE’s current measure endorsement maintenance processes as described on the PQM E&M website. The review cycles are the same, as the committee for each project reviews both the measures undergoing maintenance and new measures. The design of the CMS CBE’s endorsement maintenance process ensures the CMS CBE continues to endorse only measures meeting the current CMS CBE evaluation criteria.

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