ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACAD
1
NSGC Quality Landscape Scan Template
2
SourceMeasure ID #TitleDescriptionClinical Area (Oncology, Preconception/Prenatal, Pediatric, Cardiology, Neurogenetics, Cross-Cutting, Other)Our refined clinical area categories - oncology, reproductive, cardiovascular, pediatric, neuro, general/medgen/adult/misc, cross-crutting/all specialties (and we can add others if we notice a need)Genetic Counselor Care Continuum Alignmentour refined alignment (heading)New care continuum alignment to bullet pointflag for group discussionMeasure Type (Outcome, Structure, Process)NumeratorDenominatorStewardData SourceFederal Program UseOther Program Use (If Applicable)Measure SetLevel of AnalysisEndorsement StatusCategory
3
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 63cAge at diagnosis documented for each blood relative noted with cancerNot SpecifiedOncologyOncologyAssessmentassessment - genetic service assessmentDetailed patient medical / family historyProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
4
American Gastroenterological Association (AGA) (https://www.gastro.org/practice-guidance/quality-and-performance-measures)N/AColorectal Cancer Screening: Testing of all patients for potential cases of Lynch Syndrome with colorectal cancer using immunohistochemistry (IHC) or microsatellite instability (MSI) by polymerase chain reaction (PCR)Percentage of patients with colorectal adenocarcinoma diagnosed on colonoscopy whose tumor has been
tested for mismatch repair deficiency using immunohistochemistry (IHC) or microsatellite instability (MSI) by
polymerase chain reaction (PCR).		OncologyOncologyAssessment
Management/Follow-up		1) triage 2) continuous assessment tools
1) Screening / risk evaluation 2) Assess and communicate risk
ConceptTesting of all patients with colorectal cancer using immunohistochemistry (IHC) or microsatellite instability (MSI)
polymerase chain reaction (PCR) to identify potential cases of Lynch syndrome. 		All patients age 18 years and older with a diagnosis of Colorectal Cancer Not SpecifiedNot SpecifiedMeasure in development for AGANot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedDirectly Relevant
5
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 63Complete family history documented for patients with invasive colorectal cancer (defect-free measure 63a - 63c)Not SpecifiedOncologyOncologyAssessmentassessment - genetic service assessmentDetailed patient medical / family historyProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
6
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP31Endometrial Carcinoma Testing for MMR, MSI, or BothPercentage of surgical pathology reports with a pathological diagnosis of endometrial carcinoma that include a statement on microsatellite instability (MSI) and/or mismatch repair immunohistochemistry.OncologyOncologyAssessment
Management/Follow-up		triageScreening / risk evaluationProcessSurgical pathology reports that contain impression or conclusion of, or
recommendation for testing of MMR, MSI, or both.

Numerator guidance:
This measure requires that immunohistochemistry (IHC) for the four MMR
proteins (MLH1, MSH2, MSH6 and PMS2);
or
MSI by DNA-based testing;
or
both are addressed in the surgical pathology report for biopsy or resection
specimens with primary or metastatic endometrial carcinoma present.
A short note can be made in the final report, such as or combination of:
• No loss of nuclear expression of MMR proteins (intact expression)
• Loss of nuclear expression of MMR protein(s)
• Microsatellite instability (MSI)
• Microsatellite instability high (MSI-H)
• Microsatellite instability low (MSI-L)
• Microsatellite stable (MSS)
• MMR, MSI, or both were previously performed
• MMR, MSI, or both is recommended
• MMR, MSI, or both cannot be determined
MMR/MSI status may be derived from either the primary or a reference
laboratory.		All surgical pathology reports with a pathological diagnosis of primary or metastatic endometrial carcinoma in either biopsy or resection specimen.Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information System and pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedDirectly Relevant
7
National Quality Measures for Breast Centers (Source: https://www.nqmbc.org/quality-measure-program/quality-measures.cms)Genetics 4Family history obtained for breast cancer patients equal or under 70 years old.Percentage of women with invasive breast cancer 70 years old and younger who have a 3 generation family history in the medical record.OncologyOncologyAssessmentassessment - genetic service assessmentDetailed patient medical / family historyProcessNot SpecifiedNot SpecifiedNQMBCNot SpecifiedNot SpecifiedNQMBC™ ProgramNQMBC - GeneticsNot SpecifiedNot EndorsedDirectly Relevant
8
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 65aGenetic counseling, referral for counseling, or genetic testing for patients with invasive colorectal cancer with increased hereditary risk of colorectal cancerNot SpecifiedOncologyOncologyTriagetriageReferral for genetic counselingProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
9
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 65Genetic testing addressed appropriately for patients with invasive colorectal cancer (defect-free measure 65a - 65c)Not SpecifiedOncologyOncologyAssessment
Management/Follow-up
1) Assessment - genetic testing assessment
ProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
10
National Quality Measures for Breast Centers (Source: https://www.nqmbc.org/quality-measure-program/quality-measures.cms)Genetics 1Genetic testing for invasive breast cancer patients equal or under 45 years old.Percentage of patients with invasive breast cancer 45 years old or younger who had genetic testing performed.OncologyOncologyAssessment
Management/Follow-up
Assessment - genetic testing assessment
Order and coordinate testingProcessNot SpecifiedNot SpecifiedNQMBCNot SpecifiedNot SpecifiedNQMBC™ ProgramNQMBC - GeneticsNot SpecifiedNot EndorsedDirectly Relevant
11
National Quality Measures for Breast Centers (Source: https://www.nqmbc.org/quality-measure-program/quality-measures.cms)Genetics 3Genetic testing for triple negative invasive breast cancer patients equal or under 60 years old.Percentage of women with triple negative invasive breast cancer 60 years old and younger who underwent genetic testing.OncologyOncologyAssessment
Management/Follow-up
Assessment - genetic testing assessment
Order and coordinate testingProcessNot SpecifiedNot SpecifiedNQMBCNot SpecifiedNot SpecifiedNQMBC™ ProgramNQMBC - GeneticsNot SpecifiedNot EndorsedDirectly Relevant
12
National Quality Measures for Breast Centers (Source: https://www.nqmbc.org/quality-measure-program/quality-measures.cms)Medical Oncology 4Genomic Assay UseUse of Genomic Assay in ER+/PR+ Node negative tumors.OncologyOncologyAssessment
Management/Follow-up		Omit (somatic testing)StructureNot SpecifiedNot SpecifiedNQMBCNot SpecifiedNot SpecifiedNQMBC™ ProgramNQMBC - Medical OncologyNot SpecifiedNot EndorsedDirectly Relevant
13
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP18Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Primary or Metastatic Colorectal CarcinomaPercentage of all primary or metastatic colorectal carcinoma surgical pathology reports that address the status of biomarker evaluation for mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6 and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.
INSTRUCTIONS: This measure is to be reported each time a primary or metastatic colorectal carcinoma pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
The results of MMR/MSI testing of a sample are frequently needed at some point during a patient’s treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of MMR/MSI testing for that sample. Referring physicians depend on both the pathologists’ interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, important tests may be missed or unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.		OncologyOncologyAssessment
Management/Follow-up		TriageScreening / risk evaluationProcessSurgical pathology reports that contain impression or conclusion of, or recommendation for testing of MMR, MSI, or both.

Numerator guidance:
This measure requires that immunohistochemistry (IHC) for the four MMR proteins (MLH1, MSH2, MSH6 and PMS2);
or
MSI by DNA-based testing;
or
both are addressed in the surgical pathology report for biopsy or resection specimens with primary or metastatic colorectal carcinoma present.
A short note can be made in the final report, such as or combination of:
• No loss of nuclear expression of MMR proteins
• Loss of nuclear expression of MMR proteins (intact expression)
• Microsatellite instability (MSI)
• Microsatellite instability high (MSI-H)
• Microsatellite instability low (MSI-L)
• Microsatellite stable (MSS)
• MMR, MSI, or both previously performed
• MMR, MSI, or both recommended
• MMR, MSI, or both cannot be determined
MMR/MSI status may be derived from either the primary or a reference laboratory.		All surgical pathology reports for primary or metastatic colorectal carcinoma in either biopsy or resection specimen.
ICD10: C18.0, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C78.0, C78.1, C78.2, C78.3, C78.4, C78.5, C78.6, C78.7, C78.8, C79.0, C79.01, C79.02, C79.1, C79.10, C79.11, C79.19, C79.2, C79.3, C79.31, C79.32, C79.4, C79.40, C79.49, C79.5, C79.51, C79.52, C79.6, C79.60, C79.61, C79.62, C79.7, C79.70, C79.71, C79.72, C79.8, C79.81, C79.82, C79.89, C79.9
CPT©: 88305, 88307, 88309		Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information Systems; pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedDirectly Relevant
14
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 65cPatient with invasive colorectal cancer counseled, or referred for counseling, to discuss results following genetic testingNot SpecifiedOncologyOncologyTriage
Assessment		TriageReferral for genetic counselingProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
15
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 63aPresence or absence of cancer in first-degree blood relatives documentedNot SpecifiedOncologyOncologyAssessmentAssessment - genetic service assessmentDetailed patient medical / family historyProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
16
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 63bPresence or absence of cancer in second-degree blood relatives documentedNot SpecifiedOncologyOncologyAssessmentAssessment - genetic service assessmentDetailed patient medical / family historyProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
17
ASCO QOPI® 2019 REPORTING TRACKS (Source: https://practice.asco.org/sites/default/files/drupalfiles/QOPI-2019-Round-1-Reporting-Tracks-Public-Posting.pdf)QOPI: 77msiProportion of patients with a diagnosis of colorectal cancer who had microsatellite instability (MSI) status determined by MS instability analysis or immunohistochemistry by mismatched repair proteins (MMR)Not SpecifiedOncologyOncologyAssessment
Management/Follow-up		TriageScreening / risk evaluationProcessNot SpecifiedNot SpecifiedAmerican Society of Clinical OncologyNot SpecifiedNot SpecifiedNot SpecifiedASCO QOPI® Not SpecifiedNot EndorsedDirectly Relevant
18
National Quality Measures for Breast Centers (Source: https://www.nqmbc.org/quality-measure-program/quality-measures.cms)Genetics 2Risk assessment performed for breast cancer patients equal or under 50 years old.Percentage of patients with invasive breast cancer 50 years old or younger who have quantitative risk assessment for genetic mutations in the medical record.OncologyOncologyTriage
Assessment		1) Triage
2) Assessment - continuous assessment tools		1) Screening / risk evaluation
2) Assess and communicate risk		ProcessNot SpecifiedNot SpecifiedNQMBCNot SpecifiedNot SpecifiedNQMBC™ ProgramNQMBC - GeneticsNot SpecifiedNot EndorsedDirectly Relevant
19
NQF Measure Incubator® Projects (Source: http://www.qualityforum.org/Proving_the_Concept.aspx)N/AAssess survival rates for individuals with lung cancer and a lung cancer PRO-PMN/AOncologyOncologyOutcomesOutcomesomit ConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
20
Consensus Core Set:Cardiovascular Measures (Source: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88908)N/AFuture Areas for Cardiovascular Care Measure Development: Heart Failure:
-Outpatient – symptom control or change in symptoms
-Functional status or quality of life measure for patients with heart failure.
-Goals of care (does not need to be specific to heart failure)
-Management of women with peripartum cardiomyopathy 		N/ACardiologycardiovascularAssessment
Management/Follow-up
Outcomes		1) Assessment - care coordination and management 2) Outcomes - Health behaviors and quality of life 1) symptom management, 2) Quality of lifeConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
21
Consensus Core Set:Cardiovascular Measures (Source: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88908)N/AFuture Areas for Cardiovascular Care Measure Development: Other:
-Additional cost and over-utilization measures.
-Mental health measures following cardiovascular events
-Symptom Management measures
-Disparities in cardiovascular care		N/ACardiologycardiovascularAssessment
Management/Follow-up
Outcomes		1) Assessment - care coordination and management 1) symptom managementConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
22
Consensus Core Set: Pediatric Measures (Source: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88914)N/AFuture Areas for Measure Development:
-Improved behavioral health measures for pediatric populations top priority of workgroup
-Patient reported outcomes
-Pediatric CG CAHPS
-#0418 - Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan. Important measure concept but concerns about reporting mechanisms. CMS/HHS push to include depression measures in programs. Consider for version 2.0.
-Adolescent well-care visit measure that includes virtual visits		N/APediatricpediatricsAssessment
Management/Follow-up
Outcomes		outcomes - health behaviors and QoL, outcomes - satistfaction/perceived usefulness, outcomes - anxiety/distressConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
23
Consensus Core Set: Medical Oncology Measures (Source: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88911)N/AFUTURE AREAS FOR MEDICAL ONCOLOGY MEASURE DEVELOPMENT:
-Functional status or quality of life
-Shared decision-making
-Under or overtreatment (will need to develop a baseline or a threshold based on data)
-ER utilization
-In patient hospital admission rate
-Cost measures		N/AOncologyoncologyAssessment
Management/Follow-up
Outcomes		outcomes - health behaviors and QoL, outcomes - satistfaction/perceived usefulness - shared/informed decision making, care coordination&management - symptom managementConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
24
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/ANotification to the ordering provider requesting myoglobin or CK-MB (creatine kinasemuscle/brain) in the diagnosis of suspected acute myocardial infarction (AMI) (Awardee: American Society for Clinical Pathology)N/ACardiologyneuroAssessment
Management/Follow-up		omitConceptN/AN/AAmerican Society for Clinical PathologyN/AMeasures under development for QPPN/AN/AN/AN/AConcept
25
NQF Measure Incubator® Projects (Source: http://www.qualityforum.org/Proving_the_Concept.aspx)N/AOutcome measures to assess survival rates for individuals with melanoma N/AOncologyoncologyOutcomescare coordination & managementConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
26
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/APatient Reported Health Related Quality of Life in Cancer Following Chemotherapy. (awardee: Pacific Business Group on Health)N/AOncologyoncologyOutcomesomit (out of scope)ConceptN/AN/APacific Business Group on HealthN/AMeasures under development for QPPN/AN/AN/AN/AConcept
27
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Number of emergency department visits per attributed OCM-FFS beneficiary per OCM-FFS episode (Risk adjusted)N/AOncologyoncologyOutcomesomit (out of scope)ConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
28
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Number of hospital admissions per attributed OCM-FFS beneficiaries per OCM-FFS episode for (Risk adjusted)N/AOncologyoncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
29
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Percentage of all Medicare FFS beneficiaries managed by a practice who experience more than one emergency department visit in the last 30 days of lifeN/AOncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
30
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Percentage of OCM-FFS beneficiaries that receive psychosocial screening and intervention at least once per OCM-FFS episodeN/AOncologyoncologyAssessment
Management/Follow-up		outcomes - anxiety/depression/distress, assessment - continuuous assessment tools - psychosocial supportConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
31
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Performance-based Payment: Percentage of OCM-FFS beneficiary face-to-face visits in which the patient is assessed by an approved patient-reported outcomes tool. This would include a minimum of the PROMIS tool short forms for anxiety, depression, fatigue, pain interference, and physical functionN/AOncologyoncologyOutcomesoutcomes
1) anxiety/depression/distress 2) quality of life
ConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
32
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APerformance-based Payment: Score on patient experience survey (CAHPS as modified by the evaluation contractor)N/AOncologyoncologyOutcomesoutcomes satistfaction with genetic counseling and testingConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
33
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APractice Requirements: Electronically document a care plan that contains the 13 components in the IOM Care Management PlanN/AOncologyoncologyAssessment
Management/Follow-up		omitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
34
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APractice Requirements: Percentage of beneficiaries who are treated with therapies consistent with nationally recognized clinical guidelinesN/AOncologyoncologyManagement/Follow-upassessmentCare Coordination and ManagementConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
35
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APractice Requirements: Provide and attest to 24 hour, 7 days a week patient access to appropriate clinician who has real-time access to practice’s medical recordN/AOncologyTriage
Assessment
Management/Follow-up		omitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
36
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/APractice Requirements: Provide core functions of patient navigationN/AOncologyTriage
Assessment
Management/Follow-up		omitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
37
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/AQuality Monitoring: Imaging utilization by OCM-FFS beneficiariesN/AOncologyoncologyAssessment
Management/Follow-up		Care Coordination and Managementrecurrent screningConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
38
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/AQuality Monitoring: Number of emergency department visits per OCM-FFS beneficiary in the 6 months following the OCM-FFS episodeN/AOncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
39
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/AQuality Monitoring: Number of hospital admissions per OCM-FFS beneficiary in the 6 months following the OCM-FFS episodeN/AOncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
40
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/AQuality Monitoring: Number of hospital readmissions per OCM-FFS beneficiary during the OCM-FFS episode and the following 6 monthsN/AOncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
41
Oncology Care Model (OCM) Request for Applications (RFA) February 2015; Preliminary List of Quality and Performance Measures (Source: https://innovation.cms.gov/files/x/ocmrfa.pdf)N/AQuality Monitoring: Number of ICU admissions per OCM-FFS beneficiary during the OCM-FFS episode and the following 6 monthsN/AOncologyOutcomesomitConceptN/AN/AN/AN/APlanned concept for Oncology Care ModelN/AN/AN/AN/AConcept
42
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/ARate of communicating results of an amended report with a major discrepancy to the responsible provider (Awardee: American Society for Clinical Pathology)N/ACross-cuttingall specialtyAssessment
Management/Follow-up		assessmentinterpretation of test resultsConceptN/AN/AAmerican Society for Clinical PathologyN/AMeasures under development for QPPN/AN/AN/AN/AConcept
43
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/ARate of critical value reporting for troponin (Awardee: American Society for Clinical Pathology)N/ACardiologyomitAssessment
Management/Follow-up		omitomitConceptN/AN/AAmerican Society for Clinical PathologyN/AMeasures under development for QPPN/AN/AN/AN/AConcept
44
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/ARate of notification to clinical providers of a new diagnosis of malignancy (Awardee: American Society for Clinical Pathology)N/AOncologyomitomitomitConceptN/AN/AAmerican Society for Clinical PathologyN/AMeasures under development for QPPN/AN/AN/AN/AConcept
45
MACRA Measure Development Grants (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/9-21-18-QPP-Measures-Cooperative-Agreement-Awardees.pdf)N/ARecovery for all patients seen for mental health and substance use care (Awardee: American Psychiatric Association)N/ACross-cuttingomitomitomitConceptN/AN/AAmerican Psychiatric AssociationN/AMeasures under development for QPPN/AN/AN/AN/AConcept
46
NQF Measure Incubator® Projects (Source: http://www.qualityforum.org/Proving_the_Concept.aspx)N/ATufts Medical Center, in collaboration with Memorial Sloan Kettering Cancer Center and Dana-Farber Cancer Institute, proposed a patient safety measure for treating cancer patients.N/AOncologyomitomitomitConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
47
Consensus Core Set: HIV / Hep C Core Measures (Source: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88910)N/AUpdated medical visit frequency measurement with virtual visits (#2079)N/ACross-CuttingomitomitomitConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
48
NQF Measure Incubator® Projects (Source: http://www.qualityforum.org/Proving_the_Concept.aspx)N/AWork with PatientsLikeMe®, with funding from the Robert Wood Johnson Foundation, to test a novel approach to gather broad patient input in developing PRO-PMsN/ACross-cuttingomitConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
49
NQF Measure Incubator® Projects (Source: http://www.qualityforum.org/Proving_the_Concept.aspx)N/AWork with Pharmacy Quality Alliance (PQA) and National Health Council (NHC), with funding from Merck & Co., Inc., to create a rubric for assessing patient engagement in quality measurement (PDF).N/ACross-cuttingomitConceptN/AN/AN/AN/AN/AN/AN/AN/AN/AConcept
50
National Quality Forum Quality Positioning System (QPS) (Source: https://www.qualityforum.org/QPS/)

2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)		NQF: 3227
MUSE1		CollaboRATE Shared Decision Making ScoreCollaboRATE is a patient-reported measure of shared decision making. CollaboRATE provides a performance score representing the percentage of respondents who experience a high level of shared decision making.
The four items include:
1) How much effort was made to help you understand your health issues?
2) How much effort was made to listen to the things that matter most to you about your health issues?
3) How much effort was made to include what matters most to you in choosing what to do next? 4) How much effort was made to explain whether treatment options are effective or not?
Each item response is given on a 10-point scale, from 0 (No effort was made) to 9 (Every effort was made). The CollaboRATE Shared Decision Making Score represents the proportion of top box scores, i.e. the proportion of all responses with scores of 9 for each of the four collaboRATE items. Patient must answer all 4 questions with a “top box” score in order to be numerator compliant. If a patient does not answer one of the four questions, this would not meet the intent of the measure. CollaboRATE was developed to be generic and was designed so that it could apply to all clinical encounters, irrespective of medical condition or patient group.		Cross-cuttingall specialitiesAssessment
Management/Follow-up
Outcomes		Genetic Testing Assessment
Outcomes (Satisfaction)		Shared decision making
Shared decision making		PRO-PMTop box scores (rating of 9 out of 9 on all four collaboRATE items).The denominator consists of all patients who complete the four CollaboRATE items, regardless of their responses. These may include patients of any demographic or medical background, as the measure is generic and applicable to a variety of clinical situations.The Dartmouth Institute for Health Policy & Clinical PracticeInstrument-Based DataMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedClinician: Group/PracticeInitial EndorsementOther Relevant Measures
51
National Quality Forum Quality Positioning System (QPS) (https://www.qualityforum.org/QPS/)NQF: 2962Shared Decision Making ProcessThis measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option. This proposal is to focus on patients who have undergone any one of 7 common, important surgical procedures: total replacement of the knee or hip, lower back surgery for spinal stenosis of herniated disc, radical prostatectomy for prostate cancer, mastectomy for early stage breast cancer or percutaneous coronary intervention (PCI) for stable angina. Patients answer four questions (scored 0 to 4) about their interactions with providers about the decision to have the procedure, and the measure of the extent to which a provider or provider group is practicing shared decision making for a particular procedure is the average score from their responding patients who had the procedure.Cross-cuttingall specialitiesAssessment
Management/Follow-up
Outcomes		Genetic Testing Assessment
Outcomes (Satisfaction)		Shared decision making
Shared decision making		PRO-PMPatient answers to four questions about whether not 4 essential elements of shared decision making (laying out options, discussing the reasons to have the intervention and not to have the intervention, and asking for patient input) were part of the interactions with providers when the decision was made to have the procedure.All responding patients who have undergone one of the following 7 surgical procedures: back surgery for a herniated disc; back surgery for spinal stenosis; knee replacement for osteoarthritis of the knee; hip replacement for osteoarthritis of the hip; radical prostatectomy for prostate cancer; percutaneous coronary intervention (PCI) for stable angina, and mastectomy for early stage breast cancer.Massachusetts General HospitalInstrument-Based DataNot SpecifiedProfessional Certification or Recognition Program, Quality Improvement (Internal to the specific organization)Not SpecifiedClinician: Group/PracticeEndorsement MaintenanceOther Relevant Measures
52
CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)

National Quality Forum Quality Positioning System (QPS) (Source: https://www.qualityforum.org/QPS/)

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Measures (Source: https://www.qualitynet.org/files/5ecd165b6c4799002344a0d4?filename=PCHQR_ProgramMan_May2020.pdf)		CMIT: 6030
NQF: 3188
PCH-36		30-Day Unplanned Readmissions for Cancer Patients30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which all adult cancer patients covered as Fee-for-Service Medicare beneficiaries have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of emergency or urgent.OncologyomitOutcomesOutcomeThis outcome measure demonstrates the rate at which adult cancer patients have unplanned readmissions within 30 days of discharge from an eligible index admission. The numerator includes all eligible unplanned readmissions to any short-term acute care hospital defined as admission to a PPS-Exempt Cancer Hospital (PCH), a short-term acute care Prospective Payment (PPS) hospital, or Critical Access Hospital (CAH) within 30 days of the discharge date from an index admission that is included in the measure denominator. Readmissions with an admission type (UB-04 Uniform Bill Locator 14) of emergency = 1 or urgent = 2 are considered unplanned readmissions within this measure. Readmissions for patients with progression of disease (using a principal diagnosis of metastatic disease as a proxy) and for patients with planned admissions for treatment (defined as a principal diagnosis of chemotherapy or radiation therapy) are excluded from the measure numerator.The denominator includes inpatient admissions for all adult Fee-for-Service Medicare beneficiaries where the patient is discharged from a short-term acute care hospital (PCH, short-term acute care PPS hospital, or CAH) with a principal or secondary diagnosis (i.e., not admitting diagnosis) of malignant cancer within the defined measurement period.Seattle Cancer Care AlianceAdministrative ClaimsProspective Payment System - Exempt Cancer Hospital Quality ReportingPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacilityEndorsedOther Relevant Measures
53
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP11Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Breast CarcinomaPercentage of surgical pathology reports for breast carcinoma with appropriate human epidermal growth factor receptor 2 (HER2) breast tumor evaluation
Three rates are submitted.
1. Percentage of surgical pathology reports for breast carcinoma with a quantitative breast tumor evaluation using HER2 IHC or ISH, that had an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm
2. Percentage of surgical pathology reports for breast carcinoma with an equivocal HER2 result obtained using the ASCO/CAP guideline optimal scoring algorithm that had a subsequent repeat HER2 test completed
3. Percentage of surgical pathology reports for breast carcinoma with a quantitative breast tumor evaluation using HER2 IHC or ISH, that had an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm AND when an equivocal HER2 result was obtained, had a subsequent repeat HER2 test completed
Performance rate 3 is the reported rate
INSTRUCTIONS: This measure is to be reported each time a breast carcinoma report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.		OncologyomitAssessment
Management/Follow-Up		ProcessNumerator 1: Pathology reports with an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm
Numerator 2: Pathology reports with an equivocal HER2 result obtained using the ASCO/CAP guideline optimal scoring algorithm that had a subsequent repeat HER2 test completed
Numerator 3: Pathology reports with an HER2 result derived using the ASCO/CAP guideline optimal scoring algorithm AND when an equivocal result was obtained, had a subsequent repeat HER2 test*
Definition: Repeat HER2 test can be completed either by using a different methodology* or the same methodology with an alternative specimen.
* in situ hybridization (ISH) assay or immunohistochemical (IHC) assay		All surgical pathology reports for breast carcinoma with a quantitative breast tumor evaluation using HER2 IHC or ISH.Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information Systems; pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
54
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP12Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Gastroesophageal AdenocarcinomaPercentage of patients diagnosed with gastroesophageal adenocarcinoma (GEA) cancer (primary or metastatic) for which biopsies, resection, or metastatic specimens have HER2 evaluation conducted using the current ASCO/CAP recommended manual system or computer-assisted system consistent with the optimal algorithm.
INSTRUCTIONS: This measure should be submitted when quantitative HER2 evaluation is conducted during the performance period for patients with gastroesophageal adenocarcinoma. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
This measure has two performance rates that contribute to the overall performance score:
1. Percentage of all pathology reports for GEA cancer biopsies or resection specimens (primary or metastasis) for patients with known GEA that have HER2 immunohistochemistry (IHC) evaluation conducted using the current ASCO/CAP recommended optimal scoring algorithm completed.
2. Percentage of pathology reports GEA cancer patients with equivocal (IHC 2+) human epidermal growth factor receptor 2 (HER2) testing result that had a follow-up HER2 evaluation completed using in-situ hybridization (ISH).
The overall performance score is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).		OncologyomitAssessment
Management/Follow-Up		ProcessNumerator1: GEA cancer biopsies or resection specimens (primary or metastatic) with an optimal scoring algorithm for HER2 IHC testing completed consistent with the current ASCO/CAP guideline.
HER2 IHC result may include:
• Negative (IHC 0)
• Negative (IHC 1+)
• Equivocal (IHC 2+)
• Positive (IHC 3+)
• Indeterminate
Numerator note: HER2 testing on fine-needle aspiration (FNA) specimens (cell blocks) is an acceptable alternative.
Numerator 2: GEA cancer patients with a result of IHC 2+ (equivocal) who had a follow up HER2 test using ISH.
HER2 ISH result may include:
• Negative (not amplified)
• Positive (amplified)
• Indeterminate		All pathology reports for GEA cancer patients with a tumor evaluation using HER2 IHC.
ICD-10: C15.3, C15.4, C15.5, C15.8, C15.9, C16.0, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C16.9
CPT®: 88342, 88360, 88361, 88365, 88367, 88368		Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information Systems; pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
55
CMS List of Measures Under Consideration (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Measures-under-Consideration-List-for-2018.pdf)

HEDIS 2020 Measures (Source: https://www.ncqa.org/wp-content/uploads/2019/07/20190701_HEDIS_2020_Measures_Summary_of_Changes.pdf)		MUC19-112
HEDIS: AHU		Acute Hospital Utilization (AHU)This measure assesses the risk-adjusted ratio of observed-to-expected inpatient admission and observation stay discharges during the measurement year reported by surgery, medicine and total among members 18 years of age and older.Cross-cuttingomitOutcomesResource UseReporting: Number of Observed Events among Non-Outlier Members The number of observed discharges within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Reporting: Number of Expected Events among Non Outlier Members The number of expected discharges within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Note: Observed rate and Expected rate should be calculated per 1,000 non-outlier members.The number of non-outlier members in the eligible population for each age and gender group and the overall total. Reporting: Number of Outlier Members The number of outlier members for each age and gender group and the overall total. Reporting: Number of NonOutlier Members The number of non-outlier members for each age and gender group and the overall total.National Committee for Quality Assurance (NCQA)Not SpecifiedConsidered for Merit-based Incentive Payment System (MIPS) (not recommended)Not SpecifiedHEDIS SetHealth PlanNot EndorsedOther Relevant Measures
56
Pediatric Quality Measures Program (PQMP) (Source: https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html)NQF: 2789Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health CareThe ADAPT is a survey of adolescents with a chronic health condition that assesses their experiences with preparation for transition from pediatric-focused to adult-focused health carePediatricomitAssessment
Management/Follow-Up		Patient ExperienceThe ADAPT survey measures the quality of health care transition preparation for youth with chronic health conditions, based on youth report of whether specific recommended processes of care were received. Responses from a survey sample derived from a clinical program or health plan are summarized in three domain-level composite scores.ADAPT composite scores are calculated using the summation of positive responses to between three and five individual items. For survey items within each composite score, the denominator is the number of respondents for whom the item is scored as 0 or 1. Complete instructions for composite score calculations are provided in Section 2, Detailed Measure Specifications (see Supporting Documents). Another relevant attribute for a survey measure is the survey response rate. The response rate denominator for this measure is the total number of surveys mailed but not returned (nonresponses), excluding surveys that are undeliverable or returned with a clear indication that the 3 sampled individual is ineligible for survey completion. Complete instructions for response rate calculations are provided in Section 2, Detailed Measure Specifications (see Supporting Documents). Center of Excellence for Pediatric Quality Measurement (CEPQM)Instrument-Based DataPediatric Quality Measures Program (PQMP)Not in use, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedClinician: Group/Practice, Facility, Health PlanEndorsedOther Relevant Measures
57
MIPS 2020 Quality Measure List (https://qpp.cms.gov/mips/explore-measures/quality-measures)107Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentPercentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedOtheromitAssessment
Management/Follow-Up		omitProcessPatients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedAll patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)Physician Consortium for Performance ImprovementNot SpecifiedMerit-based Incentive Payment System (MIPS) Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
58
CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)

MIPS 2020 Quality Measure List (https://qpp.cms.gov/mips/explore-measures/quality-measures)		CMIT ID: 2573
MIPS: 439		Age Appropriate Screening Colonoscopy The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.OncologyomitTriage
Assessment		EfficiencyAll patients greater than 85 years of age included in the denominator who did NOT have a history of colorectal cancer or a valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn s Disease (i.e. regional enteritis), familial adenomatous polyposis, Lynch Syndrome (i.e., hereditary non- polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal findings of gastrointestinal tract, or changes in bowel habits. Colonoscopy examinations performed for screening purposes onlyColonoscopy examinations performed on patients greater than 85 years of age during the encounter periodAmerican Gastroenterological AssociationRegistry DataMerit-based Incentive Payment System (MIPS) Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
59
HEDIS 2020 Measures (Source: https://www.ncqa.org/wp-content/uploads/2019/07/20190701_HEDIS_2020_Measures_Summary_of_Changes.pdf)HEDIS: AMBAmbulatory Care (AMB)This measure summarizes utilization of ambulatory care in the following categories:
• Outpatient Visits including telehealth.
• ED Visits.		Cross-CuttingomitOutcomesResource UseDetailed measure calculation information is included in HEDIS Vol. 2 specificationsDetailed measure calculation information is included in HEDIS Vol. 2 specificationsNational Committee for Quality Assurance (NCQA)Not SpecifiedNot SpecifiedNot SpecifiedHEDIS SetHealth PlanNot EndorsedOther Relevant Measures
60
Medicaid 2020 Child Core Set (https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2020-child-core-set.pdf)Not SpecifiedAmbulatory Care: Emergency Department (ED) Visits (AMB-CH)Not SpecifiedCross-cuttingomitOutcomesOutcomeNot SpecifiedNot SpecifiedNational Committee for Quality Assurance (NCQA)Administrative Medicaid 2020 Child Core SetNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
61
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP13Anaplastic Lymphoma Kinase (ALK) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung CancerPercentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include anaplastic lymphoma kinase (ALK) mutation status.
INSTRUCTIONS: This measure is to be reported each time a non-small cell lung cancer specimen pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
The results of ALK testing of a specimen are frequently needed at some point during a patient’s treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of ALK testing for that specimen. Referring physicians depend on both the pathologists’ interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.		OncologyomitAssessment
Management/Follow-Up		ProcessSurgical pathology reports that contain impression or conclusion of, or recommendation for ALK mutation testing.
Numerator guidance
A short note on ALK mutation status can be made in the final report, such as:
• ALK mutation(s) identified / positive
• No ALK mutation(s) identified / negative
• ALK previously performed
• ALK mutation testing recommended
• ALK mutation cannot be determined
ALK mutation status may be derived from either the primary or a reference laboratory.		All surgical pathology reports with a diagnosis of NSCLC.Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information Systems; pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
62
National Quality Forum Quality Positioning System (QPS) (https://www.qualityforum.org/QPS/)NQF: 0579Annual cervical cancer screening or follow-up in high-risk womenThis measure identifies women age 12 to 65 diagnosed with cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS prior to the measurement year, and who still have a cervix, who had a cervical CA screen during the measurement year.OncologyomitTriage
Assessment		ProcessPatients in the denominator who had a cervical CA screen during the measurement yearWomen who are 12-65 years of age who have a diagnosis of cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS diagnosed prior to the measurement year, and who still have a cervix (excludes women with a hysterectomy and no residual cervix).
Exclusions:
No claims for cervical cancer screening exclusions, based on NCQA/HEDIS technical specifications: Women who had a hysterectomy with no residual cervix.		Resolution Health, Inc.Claims, Electronic Health DataNot SpecifiedPublic Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedClinician: Group/Practice, Clinician: Individual, Health Plan, Integrated Delivery System, Population: Community, County or CityEndorsement RemovedOther Relevant Measures
63
MIPS 2020 Quality Measure List (https://qpp.cms.gov/mips/explore-measures/quality-measures)

HEDIS 2020 Measures (Source: https://www.ncqa.org/wp-content/uploads/2019/07/20190701_HEDIS_2020_Measures_Summary_of_Changes.pdf)		MIPS: 009
HEDIS: AMM		Anti-Depressant Medication Management (AMM)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)		OtheromitManagement/Follow-upProcessNumerator 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date.

Numerator 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date.		Patients 18 years of age and older who were dispensed antidepressant medications within 245 days (8 months) prior to the measurement period through the first 120 days (4 months) of the measurement period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event and had a visit 60 days prior to, or 60 days after the dispensing eventNational Committee for Quality Assurance (NCQA)Claims and electronic health record dataMerit-based Incentive Payment System (MIPS) NCQA Health Plan AccreditationHEDIS SetNot SpecifiedNot EndorsedOther Relevant Measures
64
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)MBHR2Anxiety Response at 6-monthsThe percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who demonstrated a response to treatment at six months (+/- 60 days) after an index visitOtheromitAssessment
Management/Follow-Up		PRO-PMThe number of patients in the denominator who demonstrated a response to treatment, with a GAD-7 result that is reduced by 25% or greater from the index GAD-7 score, six months (+/- 60 days) after an index visitAdult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) and an initial (index) GAD-7 score of 8 or higher.MBHR Mental and Behavioral Health RegistryMBHR Mental and Behavioral Health Registry: Claims, EHR, Paper medical record, registryMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
65
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)MBHR1Anxiety ScreeningThe percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, GAD-2, BAI) during measurement periodOtherall specialtiesAssessment
Management/Follow-Up		1) continuous assessment tools (2) outcomes - Anxiety/depression/distress1) psychosocial support (2) Anxiety/depression/distressProcessAdult patients (18 years of age or older) included in the denominator who have at least one standardized tool administered and completed during a four-month measurement period. If positive (e.g., a score equal to or greater than 10 on the GAD-7), this suggests a probable anxiety diagnosis which requires documentation of an appropriate follow-up plan such as further evaluation or referral to treatment.Adult patients (18 years of age or older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) F40.1 Social phobias
F40.10 Social phobia, unspecified
F40.11 Social phobia, generalized
F41.0 Panic disorder without agoraphobia
F41.1 Generalized anxiety disorder
F41.3 other mixed anxiety disorders
F41.8 other specified anxiety disorders
F41.9 anxiety disorder unspecified
F43.1 Post-traumatic stress disorder (PTSD)
F43.10 Post-traumatic stress disorder, unspecified
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic		MBHR Mental and Behavioral Health RegistryMBHR Mental and Behavioral Health Registry: Claims, EHR, Paper medical record, registryMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
66
Hospital Compare (Source: https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html#%20)

Hospital Outpatient Quality Reporting (HOQR) (Source: https://www.qualitynet.org/outpatient/oqr/measures)

MIPS 2020 Quality Measure List (https://qpp.cms.gov/mips/explore-measures/quality-measures)		OP-29
NQF: 0658
MIPS: 320		Appropriate follow-up interval for normal colonoscopy in average risk patientsPercentage of patients receiving appropriate recommendation for follow-up screening colonoscopyOncologyOmitTriage
Assessment		ProcessPatients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy reportAll patients aged 50 years to 75 years and receiving screening a screening colonoscopy without biopsy or polypectomyAmerican Gastroenterological AssociationClaims, Electronic Health Data, Electronic Health Records, Other, Registry DataAmbulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting, Merit-based Incentive Payment System (MIPS)Not SpecifiedNot SpecifiedClinician: Group/Practice, Clinician: IndividualEndorsedOther Relevant Measures
67
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)GIQIC15Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patientsPercentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas, Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component), Sessile serrated polyp ≥ 10 mm OR sessile serrate polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopyOncologyomitTriage
Assessment		ProcessNumber of average-risk patients aged 50 years and older receiving a complete and adequately prepped screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas OR Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component) OR Sessile serrated polyp ≥ 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopyAll complete and adequately prepped screening colonoscopies of average-risk patients aged 50 years and older with biopsy or polypectomy and pathology findings of 3-10 adenomas, OR Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component) OR Sessile serrated polyp ≥ 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated adenomaGIQuIC, New Hampshire Colonoscopy Registry (NHCR)GIQuIC: EHR (enter relevant parts); Paper medical record

New Hampshire Colonoscopy Registry (NHCR): EHR (enter relevant parts); NHCR Data Collection Forms, Web-Based data collection, Paper Medical Record, EMR		Merit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
68
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)GIQIC17Appropriate follow-up interval of 5 years for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasiaPercentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of sessile serrated polyp(s) < 10 mm without dysplasia with a recommended follow-up interval of 5 years for repeat colonoscopy documented in their colonoscopy reportOncologyomitTriage
Assessment		ProcessNumber of average-risk patients aged 50 years and older receiving a complete and adequately prepped screening colonoscopy with biopsy or polypectomy and pathology findings of sessile serrated polyp(s) < 10 mm without dysplasia who had a recommended follow-up interval of 5 years for repeat colonoscopyAll complete and adequately prepped screening colonoscopies of average-risk patients aged 50 years and older with biopsy or polypectomy and pathology findings of sessile serrated polyp(s) < 10 mm without dysplasiaGIQuIC, New Hampshire Colonoscopy Registry (NHCR)GIQuIC: EHR (enter relevant parts); Paper medical record

New Hampshire Colonoscopy Registry (NHCR): EHR (enter relevant parts); Paper medical record		Merit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
69
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)GIQIC21Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm OR of 10 years for colonoscopies with only hyperplastic polyp findings in rectum or sigmoidPercentage of average-risk patients aged 50 years to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 1 of 2 tubular adenomas < 10 mm with a recommended follow-up interval of not less than 5 years OR pathology findings of only hyperplastic polyp findings in rectum or sigmoid with a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy reportOncologyomitTriage
Assessment		ProcessNumber of average-risk patients aged 50 years to 75 years receiving a complete and adequately prepped screening colonoscopy with biopsy or polypectomy and: (Strata 1) pathology findings of 1 to 2 tubular adenomas < 10 mm who had a recommended follow-up interval of ≥ 5 years for repeat colonoscopy OR (Strata 2) pathology findings of only hyperplastic polyp(s) in rectum or sigmoid who had a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy reportAll complete and adequately prepped screening colonoscopies of average risk patients aged 50 years to 75 years with biopsy or polypectomy and pathology findings of: (Strata 1) 1 to 2 tubular adenomas < 10 mm OR (Strata 2) only hyperplastic polyp(s) in rectum or sigmoidGIQuIC, New Hampshire Colonoscopy Registry (NHCR)New Hampshire Colonoscopy Registry (NHCR): EHR (enter relevant parts); Paper medical record

GIQuIC: EHR (enter relevant parts); Paper medical record		Merit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
70
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)GIQIC12Appropriate indication for colonoscopyPercentage of colonoscopy procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documentedOncologyoncologyTriage
Assessment		1) Triage
2) Assessment		1) Screening / risk evaluation
2) Recurring screening		ProcessNumber of colonoscopies performed for an indication that is included in a published standard list of appropriate indicationsAll colonoscopiesGIQuIC, New Hampshire Colonoscopy Registry (NHCR)GIQuIC: EHR (enter relevant parts); Paper medical record

New Hampshire Colonoscopy Registry (NHCR): Other (describe source); NHCR Data Collection Forms, Web-Based data collection, Paper Medical Record, EMR		Merit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
71
Pediatric Quality Measures Program (PQMP) (Source: https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html)Not SpecifiedAppropriateness of Red Cell Transfusions in the Pediatric Intensive Care Unit (PICU)Percentage of transfusions in PICU patients who have a hemoglobin of less than or equal to 7 (rounding down for 7.5 or less).PediatricomitManagement/Follow-upProcessNumber of transfusions in PICU patients who have a hemoglobin of less than or equal to 7 grams/deciliter (roundi down for 7.5 or less).Number of transfusions performed in the PICU during the reporting period.
- All patients with cyanotic heart disease.
Exclusions - All patients with unstable shock.1
- All patients who are actively bleeding or have acute hemolysis.
- All patients who are on ECMO.
- All patients with sickle cell disease.
1: The addition of or an increase in a continuous infusion of any cardioactive drug within the last 24 hours.		Pediatric Measurement Center of Excellence (PMCoE)Not SpecifiedPediatric Quality Measures Program (PQMP)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
72
CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)

Medicaid 2020 Child Core Set (https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2020-child-core-set.pdf)		CMIT: 2828
NQF: 1360		Audiological Diagnosis No Later Than 3 Months of Age (AUD-CH)Percentage of newborns who did not pass hearing screening and have an audiological diagnosis no later than 3 months of age (90 days).PediatricomitTriage
Assessment		ProcessThe number of infants born during the measurement year who have not passed ("Fail / Refer") hearing screening and whose age is less than 91 days at the time of audiological diagnosis.
To be included in the numerator, infants must meet the following criteria:
Hearing screening results indicate Fail / Refer (denominator population) AND
Have an Audiological Diagnosis (SNOMED-CT equals Hearing Normal 164059009, Permanent Conductive 44057004, Sensorineural 60700002, Mixed 77507001, OR Auditory Neuropathy Spectrum Disorder 443805006) AND
Age of diagnosis is less than 91 days at the time of diagnosis.		The number of infants born during the measurement year who have not passed ("Fail / Refer") hearing screening as indicated by the following criteria:
LOINC# 54109-4: Newborn hearing screen right = Refer LA10393-9 OR
LOINC# 54108-6: Newborn hearing screen left = Refer LA10393-9		Centers for Disease Control and Prevention (CDC) Other
Electronic Clinical Data
EHR
Registry		MedicaidNot SpecifiedNot SpecifiedClinician/GroupEndorsedOther Relevant Measures
73
Pediatric Quality Measures Program (PQMP) (Source: https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html)Not SpecifiedAvailability of Multidisciplinary Outpatient Care with High-Risk PregnanciesThe percentage of high-risk pregnant women seen by at least three specified types of clinicians during their pregnancies. Preconception/Prenatalreproductive TriageTriageReferral to genetic counselingProcessThe number of eligible high-risk pregnant women seen as an outpatient by at least three specified types of clinicians during their pregnancies.
Numerator elements: Maternal ICD-9 codes to identify qualifying pregnancies, outpatient visits, and provider specialty. Provider or specialty designation should be identified using data available before analysis, according to local (State) standards for specialty identification, credentialing, and licensure. When more than one clinician is associated with a single clinical encounter, all associated specialties or disciplines should be considered to have been seen. 		Overall number of eligible qualifying high-risk pregnancies using the indicated look-back period. Eligible high-risk pregnancies are identified using maternal ICD-9 codes specified in the detailed measure specifications (see Supporting Documents); the look-back period is also provided in the technical specifications.Collaboration for Advancing Pediatric Quality Measures (CAPQuaM). Administrative data (e.g., claims data), paper medical record, electronic medical record (EMR).Pediatric Quality Measures Program (PQMP)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
74
Pediatric Quality Measures Program (PQMP) (Source: https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html)Not SpecifiedAvailability of Outpatient Maternal Fetal Medicine and Specialty Care for Women with High-Risk PregnanciesThe extent to which women with high-risk pregnancies have outpatient visits with a maternal fetal medicine specialist or specialist during pregnancyPreconception/Prenatalreproductive TriagetriageReferral to genetic counselingProcessThis measure has eight sub-measures for which the numerator is constructed as the number of eligible high-risk pregnant women who have the specified number of maternal fetal medicine or indicated subspecialty visits during their pregnancy. The last sub-measure describes the extent to which high-risk pregnant women lack prenatal care.Maternal ICD-9 codes to identify qualifying pregnancies, outpatient visits, and provider specialty. Provider or specialty designation should be identified using data available before analysis, according to local (State) standards for specialty identification, credentialing and licensure. When more than one clinician is associated with a single clinical encounter, all associated specialties or disciplines should be considered to have been seen.Collaboration for Advancing Pediatric Quality Measures (CAPQuaM). Not SpecifiedPediatric Quality Measures Program (PQMP)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
75
CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)CMIT: 1180
NQF: 0645
MIPS: 265		Biopsy Follow-UpPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patientCross-cuttingomitAssessment
Management		omitomitProcessPatients whose biopsy results have been reviewed and communicated to the primary care/referring physician and the patient by the provider and/or office and medical team. There must also be acknowledgement and/or documentation of the communication in a biopsy tracking log and document in the patient s medical recordAll new patients undergoing a biopsyAmerican Academy of DermatologyPaper Medical Records
Registry
Medical Record		Merit-based Incentive Payment System (MIPS) Not SpecifiedNot SpecifiedClinician/GroupEndorsement RemovedOther Relevant Measures
76
2020 QCDR Measure Specifications (Source: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/804/2020%20QCDR%20Measure%20Specifications.xlsx)CAP15BRAF Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Metastatic Colorectal AdenocarcinomaPercentage of metastatic colorectal adenocarcinoma surgical pathology reports that address biomarker evaluation for BRAF mutation.
INSTRUCTIONS: This measure is to be reported each time a primary colorectal adenocarcinoma pathology report is finalized during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
The results of BRAF testing of a sample are frequently needed at some point during a patient’s treatment. Pathologists are uniquely well positioned at the time of signing out the surgical pathology report to detail the disposition of BRAF testing for that sample. Referring physicians depend on both the pathologists’ interpretations of and any recommendations for tests in order to provide quality patient care. If the status is not indicated in each pathology report for the patient, important tests may be missed or unnecessary repeat testing may be performed delaying treatment and increasing cost. This measure monitors the success of pathologists in effectively communicating this important information for the purpose of care coordination and efficient use of resources.		OncologyomitAssessment
Management/Follow-Up		omitProcessSurgical pathology reports that contain impression or conclusion of, or recommendation for BRAF testing.
Numerator guidance:
A short note can be made in the final report, such as:
• BRAF mutation / positive
• No BRAF mutations detected / negative
• BRAF previously performed
• BRAF mutation testing recommended
• BRAF mutation cannot be determined
BRAF mutation status may be derived from either the primary or a reference laboratory.
CPT®: 81210, 81212, 81445, 81455		All surgical pathology reports with a diagnosis of metastatic colorectal adenocarcinoma
ICD10: C18.0, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C78.0, C78.1, C78.2, C78.3, C78.4, C78.5, C78.6, C78.7, C78.8, C79.0, C79.01, C79.02, C79.1, C79.10, C79.11, C79.19, C79.2, C79.3, C79.31, C79.32, C79.4, C79.40, C79.49, C79.5, C79.51, C79.52, C79.6, C79.60, C79.61, C79.62, C79.7, C79.70, C79.71, C79.72, C79.8, C79.81, C79.82, C79.89, C79.9
CPT®: 88305, 88307, 88309		Pathologists Quality RegistryPathologists Quality Registry: Other (describe source); Laboratory Information Systems; pathology reportsMerit-based Incentive Payment System (MIPS) QCDRNot SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
77
National Quality Forum Quality Positioning System (QPS) (https://www.qualityforum.org/QPS/)NQF: 0031Breast Cancer ScreeningPercentage of women 40-69 years of age who had a mammogram to screen for breast cancerOncologyOncologyTriage
Assessment		1) Triage
2) Assessment 		1) screening/risk evaluation
2) recurring screening		ProcessOne or more mammograms during the measurement year or the year prior to the measurement yearWomen 42–69 years of age as of Dec 31 of the measurement year (note: this denominator statement captures women age 40-69 years)
Exclusions:
Exclusion: Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies. Look for evidence of a bilateral mastectomy as far back as possible int he member´s history thorugh Dec 31 of the measurement year.		National Committee for Quality Assurance (NCQA)Claims, Electronic Health Records, OtherNot SpecifiedProfessional Certification or Recognition Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization), Regulatory and Accreditation ProgramsNot SpecifiedClinician: Group/Practice, Clinician: Individual, Health Plan, Population: Regional and StateEndorsement RemovedOther Relevant MeasuresEmily up to here 7/20/23 (not including this one)
78
CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)

National Quality Forum Quality Positioning System (QPS) (https://www.qualityforum.org/QPS/)

Medicare Part C &D Star Ratings (Source: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Star-Ratings-Technical-Notes-Oct-10-2019.pdf)

Quality Rating System (QRS) Measure Set (Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2020-QRS-Measure-Tech-Specs_20190925_508.pdf)

Medicaid 2020 Adult Core Set (Source: https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2020-adult-core-set.pdf)

MIPS 2020 Quality Measure List (https://qpp.cms.gov/mips/explore-measures/quality-measures)		CMIT: 2508 / 4005 / 5779
NQF: 2372
MIPS: 112
HEDIS: BCS
C01		Breast Cancer Screening (BCS)The percentage of women 52-74 years of age who had a mammogram to screen for breast cancer.OncologyOncologyTriage
Assessment		1) Triage
2) Assessment 		1) screening/risk evaluation
2) recurring screening		ProcessOne or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement yearWomen age 52 to 74 years as of December 31 of the measurement yearNational Committee for Quality Assurance (NCQA)Claims, Electronic Health DataMerit-based Incentive Payment System (MIPS), Medicaid Adult Core Set, Medicare Shared Savings Program (MSSP), Medicare Advantage Part C Stars, Physician CompareNCQA Health Plan AccreditationHEDIS SetHealth PlanEndorsedOther Relevant Measures
79
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)ACO-4
MIPS: 321		CAHPS: Access to SpecialistsNot SpecifiedCross-CuttingomitOutcomesPatient ExperienceNot SpecifiedNot SpecifiedCenters for Medicare & Medicaid Services (CMS) / Agency for Healthcare Research and Quality (AHRQ)SurveyMedicare Shared Savings Program, Merit-based Incentive Payment System (MIPS)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
80
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Communication with doctors (composite measure)Not SpecifiedCross-Cuttingcrosscutting, inpatientOutcomes1) Assessment, 2)Outcomes1) patient education
2) decisional conflict, satisfaction		Patient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
81
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Discharge information (composite measure)Not SpecifiedCross-CuttingomitOutcomesPatient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
82
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Overall rating of hospital (global rating; single-item measure)Not SpecifiedCross-CuttingomitOutcomesPatient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
83
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Patients understood their care when they left the hospital (composite measure)Not SpecifiedCross-CuttingomitOutcomesPatient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
84
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Responsiveness of hospital staff (composite measure)Not SpecifiedCross-CuttingomitOutcomesPatient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
85
CAHPS: Adult Hospital Survey (Source: https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html)NQF: 0166CAHPS: Adult Hospital Survey: Willingness to recommend the hospital (global rating; single-item measure)Not SpecifiedCross-CuttingomitOutcomesPatient ExperienceThe HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.

For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:

https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf		The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.Centers for Medicare & Medicaid Services (CMS)Patient Survey; Instrument-Based DataHospital Compare, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Prospective Payment System (PPS)-Exempt Cancer Hospital Quality ReportingPayment Program, Public ReportingNot SpecifiedFacilityEndorsedOther Relevant Measures
86
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)ACO-46
MIPS: 321		CAHPS: Care CoordinationNot SpecifiedCross-CuttingomitOutcomesnot enough informationPatient ExperienceNot SpecifiedNot SpecifiedNot SpecifiedSurveyMedicare Shared Savings Program, Merit-based Incentive Payment System (MIPS)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
87
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)

CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)		ACO-1
MIPS: 321
NQF: 0005
CMIT ID: 2856 		CAHPS: Getting Timely Care, Appointments, and InformationThe Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey 3.0 (CG-CAHPS) is a standardized survey instrument that asks patients to report on their experiences with primary or specialty care received from providers and their staff in ambulatory care settings over the preceding 6 months.

The CG-CAHPS 3.0 survey can be used in both primary care and specialty care settings. The adult survey is administered to patients aged 18 and over. The child survey is administered to the parents or guardians of pediatric patients under the age of 18. Patients who had at least one visit to a selected provider during the past 6 months are eligible to be surveyed.

CG-CAHPS Survey Version 1.0 was endorsed by NQF in July 2007 (NQF #0005) and version 2.0 received maintenance endorsement in early 2015. Version 3.0 was released in July 2015. The development of the survey is through the CAHPS Consortium and sponsored by the Agency for Healthcare Research and Quality. The survey is part of the CAHPS family of patient experience surveys and is available at https://cahps.ahrq.gov/surveys-guidance/cg/about/index.html

The Adult CG-CAHPS Survey 3.0 has 31 questions including one overall rating of the provider and 13 questions used to create these four multi-item composite measures of care or services provided:

1. Getting Timely Appointments, Care, and Information (3 items)
2. How Well Providers Communicate With Patients (4 items)
3. Helpful, Courteous, and Respectful Office Staff (2 items)
4. Providers’ Use of Information to Coordinate Patient Care (3 items)

The Child CG-CAHPS Survey 3.0 has 39 questions including one overall rating of the provider and 12 questions used to create these four multi-item composite measures of care or services provided:

1. Getting Timely Appointments, Care, and Information (3 items)
2. How Well Providers Communicate With Patients (4 items)
3. Helpful, Courteous, and Respectful Office Staff (2 items)
4. Providers’ Use of Information to Coordinate Patient Care (2 items)		Cross-Cuttingcrosscutting Outcomes1) Triage 2) Outcomes1) referral to genetic counseling 2) cost effectiveness, utility, mode of genetic counselingPatient ExperienceThe CG-CAHPS Survey item and composites are often reported using a top box scoring method. The top box score refers to the percentage of patients whose responses indicated that they “always” received the desired care or service for a given measure.

The top box numerator for the Overall Rating of Provider is the number of respondents who answered 9 or 10 for the item, with 10 indicating “Best provider possible”.

For more information on the calculation of reporting measures, see
“Preparing Data from CAHPS® Surveys for Analysis” (AHRQ, 2017) accessible at
https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/preparing-data-for-analysis.pdf
and the CAHPS Analysis Instructions accessible at https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/2015-instructions-for-analyzing-data.pdf (updated June 2017).		The measure’s denominator is the number of survey respondents. The target populations for the surveys are patients who have had at least one visit to the selected provider in the target 6-month time frame. This time frame is also known as the look back period. The sampling frame is a person-level list and not a visit-level list.Agency for Healthcare Research and Quality (AHRQ)Instrument-Based DataMedicare Shared Savings Program, Merit-based Incentive Payment System (MIPS)Payment Program, Professional Certification or Recognition Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization), Regulatory and Accreditation ProgramsNot SpecifiedClinician: Group/PracticeEndorsedOther Relevant Measures
88
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)ACO-5
MIPS: 321		CAHPS: Health Promotion and EducationNot SpecifiedCross-CuttingomitOutcomesomitPatient ExperienceNot SpecifiedNot SpecifiedCenters for Medicare & Medicaid Services (CMS) / Agency for Healthcare Research and Quality (AHRQ)SurveyMedicare Shared Savings Program, Merit-based Incentive Payment System (MIPS)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
89
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)ACO-7
MIPS: 321		CAHPS: Health Status/Functional StatusNot SpecifiedCross-CuttingomitOutcomesPatient ExperienceNot SpecifiedNot SpecifiedCenters for Medicare & Medicaid Services (CMS) / Agency for Healthcare Research and Quality (AHRQ)SurveyMedicare Shared Savings Program, Merit-based Incentive Payment System (MIPS)Not SpecifiedNot SpecifiedNot SpecifiedNot EndorsedOther Relevant Measures
90
Medicare Shared Savings Program Quality Measure Benchmarks for the 2020/2021 Performance Years (Source: https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf)

CMS Measures Inventory Tool (Source: https://cmit.cms.gov/CMIT_public/ListMeasures)		ACO-2
NQF: 0005
CMIT ID: 2861		CAHPS: How Well Your Providers CommunicateThe Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey 3.0 (CG-CAHPS) is a standardized survey instrument that asks patients to report on their experiences with primary or specialty care received from providers and their staff in ambulatory care settings over the preceding 6 months.

The CG-CAHPS 3.0 survey can be used in both primary care and specialty care settings. The adult survey is administered to patients aged 18 and over. The child survey is administered to the parents or guardians of pediatric patients under the age of 18. Patients who had at least one visit to a selected provider during the past 6 months are eligible to be surveyed.

CG-CAHPS Survey Version 1.0 was endorsed by NQF in July 2007 (NQF #0005) and version 2.0 received maintenance endorsement in early 2015. Version 3.0 was released in July 2015. The development of the survey is through the CAHPS Consortium and sponsored by the Agency for Healthcare Research and Quality. The survey is part of the CAHPS family of patient experience surveys and is available at https://cahps.ahrq.gov/surveys-guidance/cg/about/index.html

The Adult CG-CAHPS Survey 3.0 has 31 questions including one overall rating of the provider and 13 questions used to create these four multi-item composite measures of care or services provided:

1. Getting Timely Appointments, Care, and Information (3 items)
2. How Well Providers Communicate With Patients (4 items)
3. Helpful, Courteous, and Respectful Office Staff (2 items)
4. Providers’ Use of Information to Coordinate Patient Care (3 items)

The Child CG-CAHPS Survey 3.0 has 39 questions including one overall rating of the provider and 12 questions used to create these four multi-item composite measures of care or services provided:

1. Getting Timely Appointments, Care, and Information (3 items)
2. How Well Providers Communicate With Patients (4 items)
3. Helpful, Courteous, and Respectful Office Staff (2 items)
4. Providers’ Use of Information to Coordinate Patient Care (2 items)		Cross-Cuttingcross-cuttingOutcomesPatient ExperienceThe CG-CAHPS Survey item and composites are often reported using a top box scoring method. The top box score refers to the percentage of patients whose responses indicated that they “always” received the desired care or service for a given measure.

The top box numerator for the Overall Rating of Provider is the number of respondents who answered 9 or 10 for the item, with 10 indicating “Best provider possible”.

For more information on the calculation of reporting measures, see
“Preparing Data from CAHPS® Surveys for Analysis” (AHRQ, 2017) accessible at
https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/preparing-data-for-analysis.pdf
and the CAHPS Analysis Instructions accessible at https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/2015-instructions-for-analyzing-data.pdf (updated June 2017).		The measure’s denominator is the number of survey respondents. The target populations for the surveys are patients who have had at least one visit to the selected provider in the target 6-month time frame. This time frame is also known as the look back period. The sampling frame is a person-level list and not a visit-level list.Agency for Healthcare Research and Quality (AHRQ)Instrument-Based DataMedicare Shared Savings ProgramPayment Program, Professional Certification or Recognition Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization), Regulatory and Accreditation ProgramsNot SpecifiedClinician: Group/PracticeEndorsedOther Relevant Measures
91
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Nephrologists’ Communication and Caring: Do your kidney doctors seem informed and up-to-date about the health
care you receive from other doctors?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
92
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Nephrologists’ Communication and Caring: In the last 3 months, how often did you feel your kidney doctors really
cared about you as a person?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
93
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Nephrologists’ Communication and Caring: In the last 3 months, how often did your kidney doctors explain things in
a way that was easy for you to understand?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
94
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Nephrologists’ Communication and Caring: In the last 3 months, how often did your kidney doctors show respect for
what you had to say?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
95
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Nephrologists’ Communication and Caring: In the last 3 months, how often did your kidney doctors spend enough
time with you?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
96
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Quality of Dialysis Center Care and Operations: For the next questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians and social workers at this dialysis center. In the last 3 months, how often did the
dialysis center staff listen carefully to you?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
97
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Quality of Dialysis Center Care and Operations: In the last 12 months, how often were you satisfied with the way they
handled these problems?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
98
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Quality of Dialysis Center Care and Operations: In the last 3 months, did dialysis center staff keep information about you
and your health as private as possible from other patients		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
99
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Quality of Dialysis Center Care and Operations: In the last 3 months, how often did dialysis center staff behave in a
professional manner		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures
100
CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites (Source: https://ichcahps.org/Portals/0/ICH_Composites_English.pdf)NQF: 0258CAHPS: In-Center Hemodialysis Survey Global Ratings and Composites: Quality of Dialysis Center Care and Operations: In the last 3 months, how often did dialysis center staff explain blood test
results in a way that was easy to understand?		This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.OtheromitOutcomesPatient ExperienceThere are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).Patients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)		Centers for Medicare & Medicaid Services (CMS)Instrument-Based DataDialysis Facility Compare, ESRD Quality Incentive ProgramPayment Program, Public Reporting, Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization)Not SpecifiedFacility, Other, Population: Regional and StateEndorsedOther Relevant Measures