CMS Measures Management System

Training Course
Introduction to
CMS Measures
Management

Intended Audience and

Course Structure
CMS Contracting Officer Representatives (CORs)
who are managing measure contracts
Measure Developers and Associations
Individuals and Associations who are interested in
the Quality Measures and the Measure
Management System, and who have a basic
understanding of the purpose of the quality-based
healthcare
Sponsoring Organization: CMS Quality
Measurement and Value-Based Incentives Group
(QMVIG)

Learning Objectives for the

Course Series
Highlight key processes and references from
the MMS Blueprint and COR Handbook
Describe measure development,
implementation, and maintenance processes
Describe the overall responsibilities and
tasks of the COR and the Measures
Management Support Contractor
Identify measure developer contract
deliverables and when they are due

Other Course Sessions

Introduction to CMS Measures
Management (This Course)
Measure Conceptualization (Posting Soon!)
Measure Specification (March 2016)
Measure Testing (June 2016)
Measure Implementation (TBA)
Measure Use, Continuing Evaluation, and
Maintenance (TBA)

Introduction to CMS
Measure Management
What are CMS Quality Measures?
What CMS is currently doing on Healthcare Quality
Measures?
What is the CMS Measures Management System
(MMS) and how is the MMS documented?
What are the basic steps in measure development,
implementation, and maintenance?
What are the overall roles and responsibilities of
the Measures Manager, contractor, and COR?
How can the Measures Manager help?

What are Quality Measures?

Quality measures are tools that help us
measure or quantify healthcare processes,
outcomes, patient perceptions, and
organizational structure and/or systems that
are associated with the ability to provide
high-quality health care and/or that relate to
one or more quality goals for health care.
These goals include: effective, safe, efficient,
patient-centered, equitable, and timely care.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instrume
nts/QualityMeasures/index.html
6

National Strategy for

Quality Improvement in
Health Care

Better care
Healthy
people/healthy
communities
Smarter
Spending

Source: 2012 (rev 2014) Annual Progress Report to Congress, National Strategy for Quality
Improvement in Health Care, Submitted by the U.S. Department of Health and Human
Services, Page 1

Priorities of Quality
Strategy
Making care safer by reducing harm caused in
the delivery of care
Ensuring that each person and his or her family
members are engaged as partners in their care
Promoting effective communication and
coordination of care
Promoting the most effective prevention and
treatment practices for the leading causes of
mortality, starting with cardiovascular disease.
Working with communities to promote wide use
of best practices to enable healthy living.
Making quality care more affordable for
individuals, families, employers, and
government by developing and spreading new
healthcare delivery models.
Source: 2012 (rev 2014) Annual Progress Report to Congress, National
Strategy for Quality Improvement in Health Care, Page 1

Who are Key Stakeholders

Quality Measure
Development?
CMS
Other Federal
AHRQ, ONC

Specialty
Societies/Associations
Consensus-based
entity
Consumers
Providers
http://socialhealthinsights.com/wp-

Why Measure?
Evidence-based approach to
improving health quality
Monitor health outcomes as related
to how care is delivered
Assure accountability that quality
initiatives are implemented
Transparency public reporting of
quality
10

Typical Steps in Measure

Development

11

CMS Quality Measure

Example
CMS 50 v3 Closing the referral loop: receipt of specialist
report
Percentage of patients with referrals, regardless of age,
for which the referring provider receives a report from
the provider to whom the patient was referred.
Expressed as a numerator and denominator with
exclusion statements
Initial Patient Population: Number of patients, regardless of
age, who were referred by one provider to another provider,
and who had a visit during the measurement period.
Denominator: Equals Initial Patient Population;
Exclusions: None

Numerator: Number of patients with a referral, for which the

referring provider received a report from the provider to whom
the patient was referred;
Exclusions: Not Applicable

12

Data Sources
Numerous inputs are considered at all phases of
measure management:
Claims
Assessment instruments/Web forms
Registries
Chart abstraction or electronic health records
Hybrid

13

What Are eMeasures?

An eMeasure (also called eCQM) is a
health quality measure encoded in a
Health Quality Measures Format
(HQMF). eMeasures pull the
information needed from electronic
Health Records (eHRs) to evaluate
performance.
National Quality Forum. Phrasebook: A Plain Language Guide to NQF
Jargon. Washington, DC:
http://public.qualityforum.org/NQFDocuments/Phrasebook.pdf
14

eCQM Components
All Quality Measures have similar
components, but the data for
electronic quality measures are
discretely managed in prescribed
formats on computer systems. The
same data can be used for
reporting, transmitting to other
computer systems, and presentation
in a human readable format.

15

NQF Endorsement
National Quality Forum (NQF) endorsement relies
on a set of rigorous criteria to ensure that measures
under consideration address aspects of care that are
important and feasible to measure, provide
consistent and credible information, and can be
used for quality improvement and decision-making
NQF endorses measures that meet the following
criteria:
Importance to measure and report
Scientific acceptability of the measure properties
Feasibility
Usability and use
http://www.qualityforum.org/Field_Guide/NQF_Endorsement.aspx
16

What is the CMS Measures

Management System
(MMS)?
The MMS is a set of standardized processes
and decision criteria that guide contracted
measure developers in developing,
implementing, and maintaining quality
measures. The primary goal of the Measures
Management System is to provide
information to measure developers to help
them produce high-caliber quality measures
that are appropriate for accountability
Blueprint page 1
17

Key MMS Players

CMS manages activities such as measure
development, maintenance, implementation, and
public reporting. Linked to MIDS Umbrella.
COR tasked with overseeing the measures
contract.
Measure Contractors contracted by CMS to develop
and implement quality measurement programs.
Measures Manager supports the CMS COR and
their various contractors in their work
implementing the MMS.

18

How is the MMS Documented?

CMS MMS Blueprint
Technical manual (470 pages) for measure
developers

COR Handbook
Internal CMS companion manual for the
Blueprint (53 pages)
Roles and responsibilities of the COR
Considerations for managing contracts
Deliverables and tasks to assist with
development and monitoring of work plans
Criteria for review of deliverables
Visit https://
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instrum
ents/MMS/MMS-Blueprint.html

19

MMS Support Contractor

Role

Provide Information and Training Sessions

Provide technical assistance (inquiries and referrals)
Continuously improve the Blueprint
Develop tools to improve the storage and retrieval of CMS
measure information
Assist with Harmonization (making related measures uniform or
compatible)
Support CMS planning
Provide crosscutting perspective
Inform about new developments (e.g. Environmental Scan
across all measure domains)
Participate in measures-related Affordable Care Act (ACA)
implementation
20

What Resources are

Provided by MMS Support?

Developer Support
Program Integration
Measures Inventory Updates
MUC List Input
Ad Hoc Activities
Process/Quality Improvement
Resource contact:
MMSsupport@Battelle.org
21

Contractor/Developers Role
Follow the processes in the Blueprint
Keep Measures Manager in the loop for
technical support development progresses
Submit deliverables to Measures Manager
according to contractual requirements
Consult with COR if Blueprint processes do
not meet contract needs
Meet with COR and Measures Manager after
NQF submission to identify lessons learned
22

CORs Role
Understand the Blueprint
Use the Blueprint and Handbook as guides
Notify the Measures Manager when contracts
are awarded
Ensure contractor compliance with the
Blueprint
Determine if and when variation is appropriate
Approve deliverables that are submitted
Contact Measures Manager for questions
23

Role of Individuals and

Associations
Gain an understanding of the
measure development lifecycle
Engage with feedback on the
measure development process
Utilize opportunities for input

24

Blueprint 101 Session 1

Summary
Course designed to assist Developers
/CORs by providing knowledge about
the measures development process
Quality measures are tools that
enable us to measure the performance
of the healthcare system
The Measures Management System as documented in
the Blueprint is a set of standardized processes and
decision criteria that guide contracted measure
developers in developing, implementing, and
maintaining quality measures.
The COR works with the Measures Manager to
oversee/support the work of the Measures Contractors25

Preview of BP101 Session

2: Conceptualization
What is the flow of the Measure
Lifecycle?
What are the components of Measure
Conceptualization?
What is the role of the COR
throughout Measure
Conceptualization phase?
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MMS Support Contact

Primary Support email:
MMSsupport@Battelle.
org