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Measure Implementation

Measure Rollout

When a program selects a measure for use, the measure developer prepares plans for implementation, including the initial rollout, data management and production, audit and validation, measured entity education, dry runs, and appeals processes. Measure rollout occurs after measure approval for use in a program. The rollout process may include collection of data for a dry run from all measured entities across the country and share calculated rates with the measured entities. CMS does not use dry run data for payment, but may use dry run data as a baseline for future payment years.

Measure Rollout Factors

As with the overall implementation process, the process of rolling out a measure varies significantly from one measure set to another depending on a number of factors, which may include

  • The scope of measure implementation
  • The measured entity 
  • Data collection processes
  • The ultimate use of the measure (for example, quality improvement, public reporting, pay-for-reporting, value-based purchasing)
  • The program into which the measure is adopted. Measure reporting and submission are program-specific. See the program-specific page for reporting and submission information.

Dry Runs

If a dry run occurs, the measure developer ensures the rollout plan includes support for the measured entities to

  • Improve the usability of the measure report to the measured entities in advance of implementation
  • Identify and respond to questions and concerns about the measure
  • Address issues with the report production process for process improvements prior to implementation

The measure developer documents the results from the dry run and assesses the measure’s success in meeting the program’s intentions for the dry run, such as

  • Adequacy (specificity, accuracy) of the measure specifications
  • Accuracy of the data collection method(s)
  • Accuracy of the measure results calculation(s)
  • Identification of unintended consequences, gaming, or misrepresentation (if any)
  • Accuracy and adequacy of the measured entity reports (whether they are useful to the measured entities involved and whether the measure developer is to respond to questions and concerns)

Communication & Education

When communicating and coordinating with all parties involved in the rollout, the measure developer must consider the timelines of other processes (for example, pre-rulemaking, CMS consensus-based entity projects, and quality alliances). The measure developer prepares and presents education for the end users on what is being measured and how to interpret the results. The measure developer also documents the results of any educational activities and assesses whether the activities were adequate to meet the needs of the end users of the measure.

The measure developer should report on the number of educational events, including the attendance at each 

  • Conference call and recordings of the calls
  • Web-based presentation and recordings of the presentations
  • Workshop at conferences or scientific society meetings
  • Train-the-trainer event
  • Published abstracts and manuscripts

For electronic clinical quality measures (eCQMs), measure developers should refer measure implementers to the CMS Data Element Repository (DERep) for information about the data elements associated with eCQMs used in CMS quality programs as well as the definitions and clinical focus for each data element.

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