Measure evaluation continues even after the measure is fully developed. See the Measure Maintenance Reviews page for more information. The measure must be continuously reevaluated during maintenance, with measure documents updated regularly. Although evaluation details may differ for specific reevaluations, the general principles are the same.

The measure developer, technical expert panel members, and other interested parties involved in measure maintenance, work toward ensuring impactful measures to drive health care quality improvement and inform individual choice. During measure maintenance, the measure developer must continue to evaluate the measure and provide strong evidence they conduct measure production in a rigorous manner, and the measure continues to add value to quality reporting programs.

Apply Measure Evaluation Criteria

Each measure should undergo annual updates and a rigorous, comprehensive reevaluation every 3 years to assess its continued value, based on the most current set of measure evaluation criteria.

Evaluation during maintenance should also document how the measure is performing compared to the projected trajectory in the business case. Throughout the measure evaluation process, the measure developer updates the justification for the measure and any changes to the technical specifications to demonstrate

• Aspects of care included in the specifications continue to be highly important to measure and report, supply meaningful information to persons and measured entities, and drive significant improvements in health care quality and health outcomes.
• The measurement results continue to drive significant year-over-year improvements in health care quality and health outcomes where there is variation in and/or overall, less-than-optimal performance.
• Data elements, codes, and parameters included in the specifications are the best ones to use to quantify the specific measure, and data collection imposes only a modest, proportionate burden on resources, i.e., feasibility.
• Calculations included in the specifications represent a clear and accurate reflection of the variation in the health outcome of interest, or the quality or efficiency of the care delivered.
• The measure continues to be either unique for its topic or it is the “best in class” when compared with competing measures.
• The measure is comparable with other measures in its clinical significance or difficulty.

With respect to usability and use, the measure developer should assess implementation challenges and obtain feedback from measure users. The measure developer or measure steward determines whether performance results are transparent (e.g., publicly reported), and used for accountability (e.g., pay-for-performance).

Document Result of Evaluation

The measure developer should review the Measure Evaluation Criteria for details regarding applying testing to the measure evaluation criteria. If the measure is CMS Consensus-Based Entity (CBE)-endorsed or in the process of obtaining endorsement, the measure developer should also review the CMS CBE Endorsement & Maintenance Guidebook. 

Examples of endorsement evaluations 

• Breast Cancer Screening Recall Rates
• Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival
• Waveform Capnography in Ventilated Patients: Percent of patient transport contacts with advanced airways in whom continuous waveform capnography was used.

More Information for CMS Measure Developers

Please note, the MMS Hub and Blueprint content is not CMS-specific, and the guidance is not prescriptive. CMS measure developers can find more information about measure maintenance reviews in the Blueprint Contractual Guidance and Considerations found on the Measure & Instrument Development and Support (MIDS) Library. The MIDS library is a protected website restricted to CMS and CMS MIDS contractors. MIDS developers should email MMSsupport@battelle.org to request access to the MIDS Library. Once eligibility is confirmed, the MIDS developer will receive an email with instructions on accessing the site.