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Measure Specification

Document the Measures

The measure developer must complete the detailed technical specifications, including any additional documents required to evaluate and implement the measure as intended. There are CMS templates and several documents on the CMS consensus-based entity (CBE) Submitting Standards page available to assist in documentation of specifications.

Finalize the Measure Name and Description

The measure name (or measure title) should be a very brief description of the measure’s focus and target/initial population. If it is a CMS CBE-endorsed measure, use the CMS CBE-endorsed title.

Format: [target/initial population] who received/had [measure focus]

Examples 

For measures based on appropriate use criteria addressing overuse of certain services, there are three standardized title lead-ins. 

  • Appropriate Use of ... 
  • Appropriate Non-Use of ... 
  • Inappropriate Use of ... (for inverse measures—the least desirable approach) 

For the measure description, measure developers should briefly describe the type of score (e.g., percentage, percentage rate, proportion, number), target/initial population, and focus of measurement.

Format: Patients in the target/initial population who received/had [measure focus] {during [time frame] if different than for target/initial population}

The measure description should consist of standardized phrases in a standard order. 

  • “The percentage of” 
  • [sex qualifier] if applicable (e.g., “female”)
  • “patients or individuals” 
  • “during visit or event”
  • [environment qualifier] (e.g., admitted to a post-anesthesia care unit [PACU])
  • [age qualifier] (e.g., aged 18 years and older) 
  • [denominator definition] (e.g., who are under the care of an anesthesia practitioner) 
  • [numerator criteria] (e.g., in which a formal post-anesthetic transfer of care protocol or checklist is used that includes key transfer of care elements) 

It is important to word quality measures positively when possible (i.e., to demonstrate which activity to capture in the numerator).

Examples 

  • Percentage of patients 18–75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period (CMIT Family ID 00197) (CMS CBE #0062).
  • Percentage of healthcare personnel who receive the influenza vaccination (CMIT Family ID 00390) (CMS CBE #0431).
  • Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: a) percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks); b) percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) (CMIT Family ID 00063) (CMS CBE #0105).
  • Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access (CMIT Family ID 00313) (CMS CBE #2978).

Making Changes

Information from measure testing, the public comment period, updated information gathering, or other stakeholder input may require the measure developer to make changes to technical specifications. 

Last Updated: May 2022