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Measure Use, Continuing Evaluation & Maintenance

Evaluation During Maintenance

Full development of a measure does not end measure evaluation. 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 use of sound measures to drive health care quality improvement and inform individual choice. During measure maintenance, the measure developer must continue to evaluate measures and provide strong evidence they conduct measure construction in a sound 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 three 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.
  • 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.

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

Document Results of Evaluation

The measure developer must document how the measure is performing during the maintenance stage. The CMS consensus-based entity Endorsement and Maintenance Guidebook details the measure evaluation criteria and subcriteria.

Examples of endorsement evaluations by the CMS consensus-based entity

Cost and Efficiency Final Report Fall 2020 

Person- and Family-Centered Care Technical Report 2017

All-Cause Admissions and Readmissions Technical Report 2015-2017

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