CMS MMS Blueprint v17.0 Streamlined

1 CMS MMS Blueprint Table of Contents September 2021 Page i TABLE OF CONTENTS PAGE PREFACE .. VI Evolution of the Blueprint .. vi Organization of the Blueprint materials .. vi 1 CMS QUALITY MEASURE DEVELOPMENT .. 8 Quality Across CMS .. 9 CMS Goals and Priorities .. 9 Successes to Date .. 10 Critical Challenges .. 11 2 MEASURE PRIORITIZATION AND PLANNING .. 12 CMS Measure Planning Inputs .. 12 CMS and National Healthcare Priorities .. 12 Patients, Public, and Other Stakeholders .. 13 Legislative Mandates .. 13 Quality Measure Development Plan (MDP).

2 14 Impact Assessment and Other Reports .. 15 Role of the Measure Developer in Priorities Planning .. 16 3 QUALITY MEASURE DEVELOPMENT .. 17 Measurement Theory - Structure-Process-Outcome .. 17 17 General Principles for Measure Development .. 19 Technical Principles for Measure Development .. 20 Measure Evaluation in the Measure Lifecycle .. 21 Applying Measure Evaluation Criteria .. 21 Timing of Measure 21 Measure Categorization .. 22 Roles in Measure Development .. 23 Measure Stewards .. 23 Measure Developers.

3 23 The Measures Management System (MMS) .. 23 Stakeholders .. 24 4 MEASURE CONCEPTUALIZATION .. 28 Information 29 Identify the Target Healthcare Quality Issues and Determine Their Priority Area .. 30 Conduct an Environmental Scan .. 30 Analyze Empirical Data, as Appropriate .. 31 Evaluate Information Collected During Environmental Scan and Empirical Data Analysis .. 32 Conduct a Measurement Gap Analysis to Identify Areas for New Measure Development .. 32 CMS MMS Blueprint Table of Contents September 2021 Page ii Justify the Creation of New Measures.

4 32 Apply Measure Evaluation Criteria .. 33 Prepare an Initial List of Measures or Measure Topics .. 33 Business Case Development .. 33 Business Case Best Practices .. 35 Stakeholder Engagement .. 37 Technical Expert Panel .. 37 Person and Family Engagement .. 37 Public Comment .. 38 Other Stakeholder Engagement .. 39 5 MEASURE SPECIFICATION .. 40 Measure Specifications by Measure Category .. 43 Define the Data Source(s) .. 44 Develop Specifications and Definitions .. 46 Define the Target/Initial Population.

5 46 Define the Denominator .. 47 Determine if there is a need for a Denominator Exclusion .. 48 Define the Numerator .. 48 Determine if there is a need for a Denominator Exception .. 49 Determine if there is a need for a Numerator Exclusion .. 50 Define Stratification Scheme .. 51 Use Positive Evidence .. 52 Specify the Code and/or Code Systems .. 52 Construct Data Protocol .. 52 Define Key Terms, Data Elements, Codes, and Code Systems .. 53 Describe the Level of Measurement/Analysis .. 54 Describe Sampling.

6 54 Determine Risk Adjustment .. 55 Clearly Define Any Time Intervals .. 55 Describe How to Score and Report the Measure Results .. 56 Develop the Calculation Algorithm .. 56 Document the Measures .. 57 Finalize the Measure Name and Description .. 57 Making Changes .. 58 Stakeholder Engagement in Measure 58 Special Considerations for Medicaid-Focused Measures .. 58 Harmonization .. 59 6 MEASURE TESTING .. 61 The Measure Testing Process .. 62 Testing and Measure Evaluation Criteria .. 64 Importance.

7 64 Scientific Acceptability .. 65 Feasibility .. 74 Usability and Use .. 75 Develop the Testing Work Plan .. 75 Perform Sampling .. 76 CMS MMS Blueprint Table of Contents September 2021 Page iii Implement the Plan .. 77 Analyze the Test Results .. 77 Refine the Measure .. 77 Retest the Refined Measure .. 77 Measure Testing Summary .. 77 Stakeholder Engagement During Measure Testing .. 79 Testing and Evaluation for Special Measures .. 79 7 MEASURE IMPLEMENTATION .. 81 The Implementation Process .. 81 Measure Selection.

8 82 Pre-Rulemaking Process .. 82 CMS Rulemaking Processes .. 84 Stakeholder Engagement in Measure Selection .. 84 Rollout .. 85 8 MEASURE USE, CONTINUING EVALUATION, AND MAINTENANCE .. 87 Measure Production and Monitoring .. 88 Conduct Data Collection and Ongoing Surveillance .. 89 Respond to Questions About the Measure .. 90 Monitor and Analyze the Measure Rates and Audit Findings .. 90 Perform Measure Maintenance or Early Maintenance Review, When Appropriate .. 90 Continuing Evaluation .. 91 Measure Maintenance.

9 91 Evaluation during Measure Maintenance .. 94 Apply Measure Evaluation Criteria .. 94 Document Results of Evaluation .. 94 Measure Maintenance Reviews .. 94 Annual 95 Comprehensive Reevaluation .. 95 Early Maintenance Review .. 95 Stakeholder Engagement During Measure Maintenance Reviews .. 96 9 TOOLS AND RESOURCES FOR MEASURE DEVELOPERS .. 97 Bonnie .. 97 Clinical Quality Language (CQL) Style Guide .. 97 CMS Data Element Library (DEL) .. 97 CMS Measures Inventory Tool (CMIT) .. 97 Environmental Scanning Support Tool (ESST).

10 97 De Novo Measure Scan .. 98 CMS Measures under Consideration Entry / Review Information Tool (MERIT) .. 98 CQL-to-Expression Logical Model (ELM) Translator Reference Implementation .. 98 Cypress .. 98 Electronic Clinical Quality Improvement Resource Center (eCQI Resource Center) .. 99 Electronic Clinical Quality Measure (eCQM) Logic and Implementation Guidance .. 99 CMS MMS Blueprint Table of Contents September 2021 Page iv Guide for Reading eCQMs .. 99 Measure Authoring Tool (MAT) .. 99 Measures 99 Measures Management System (MMS) Support Help Desk.