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Endorsement & Maintenance (E&M)

Coming Soon

Why are measures important? Because when tested and implemented correctly, measures can enhance the entire health care system by allowing both clinicians and patients to make informed decisions based on the patient’s health care journey. 

Battelle is a certified consensus-based entity (CBE), ensuring informed and thoughtful endorsement reviews of clinical quality and cost/resource use measures. Check out our Endorsement and Maintenance Beginner's Guide and our Guidebook below to learn more!

Endorsement & Maintenance Guidebook 

The Endorsement & Maintenance (E&M) Guidebook is a resource for measure stewards, measure developers, and organizations submitting measures to Battelle via the Partnership for Quality Measurement (PQM)™ for endorsement review. This Guidebook provides information about the various steps of the endorsement and maintenance (E&M) process, including each phased review, possible endorsement decision outcomes, the appeals process, E&M policies and procedures, and the E&M committee structure. The Guidebook also contains the PQM Measure Evaluation Rubric, a standard set of criteria in which measures submitted to Battelle are evaluated for endorsement. 

The E&M Guidebook is organized to provide an overview of E&M goals, priorities, and resources; to guide measure developers and stewards through the steps of the E&M process; and to provide key considerations for submitting measures to Battelle. 

The draft E&M Guidebook was posted for public comment on July 1, 2023 for 30 calendar days. During this commenting period, Battelle received 44 total comments from 25 organizations and 10 individuals. All comments received were posted to the PQM website and our responses have been provided as an appendix within the E&M Guidebook, noting where changes have been made. The final version of the E&M Guidebook, linked above, applies to the E&M process starting with the Fall 2023 cycle.

New for the Spring 2024 cycle! We are implementing several enhancements to the E&M committee roles, voting, and meeting structure. The enhancements maintain a 6-month timeline (Figure 1) and high standards for transparency and rigor. To learn more, please review recent changes made to the E&M process.


Measure Submission

Beginning with Fall 2023 cycle, measure developers and stewards can submit measures to Battelle for endorsement review by completing and electronically submitting the online Intent to Submit (ITS) and Full Measure Submission (FMS) forms. The ITS online form will be available on September 1, 2023 and the FMS online form will be available on October 2.

To review the items and questions within each form, templates of the ITS and FMS forms are available below:

Quality Measure Developer and Steward Agreement 

Every measure requires a measure steward. If the measure to be submitted is not owned by a government entity, the steward must also complete and submit a Quality Measure Developer and Steward Agreement Form (QMDSA). For more information about how to complete the QMDSA, please see the QMDSA Submission Instructions

Battelle will be working with all measure stewards to transition to this QMDSA. Measure stewards will only need to fill out the QMDSA form if they are a new developer/steward or have an expired National Quality Forum (NQF) measure steward contract. PQM will honor all active NQF contracts until their 3-year expiration date. Once the NQF contract expires, measure stewards must submit a QMDSA form. Measure stewards with endorsed measures requiring comprehensive reevaluation or wish to add additional measures to their current QMDSA will need to complete an Additional and Maintenance Measures Form. Each QMDSA will stand for 5 years from its effective date.  

Battelle Memorial Institute and any QMDSA Steward (measure steward) submitting one or more measures for endorsement review must sign the contractual agreements, the QMDSA and Additional Maintenance Measure Forms. 

If you have any questions, please contact [email protected]


Measure Evaluation:

Clinical quality and cost/resource use measures are evaluated using the PQM Measure Evaluation Rubric (Rubric; see Appendix D of E&M Guidebook). Measures are evaluated on five domains (Importance, Feasibility, Scientific Acceptability [i.e., Reliability and Validity], Equity, and Use and Usability. For each domain, E&M committee members determine if a measure domain has been “Met”, “Not Met but Addressable”, or “Not Met”, based on specific evaluation considerations for each area.

To support E&M committee members in their evaluation of submitted measures, Battelle created the PQM Measure Evaluation Worksheet, which provides guidance on the interpretation and application of the Rubric. The Worksheet identifies certain assertions and aspirations that measures should attempt to achieve for each of the five major domains of the Rubric. The credibility of the assertion is supported by evidence. Evidence in this context is any supporting information (e.g., testing results, research studies, technical expert panel recommendations) provided by the measure developer/steward that supports the assertions/aspirations. Measure reviewers (e.g., E&M committee members) express opinions and perspectives about the presented evidence and consider key questions to determine whether the measure assertions/aspirations made by the developer/steward are credible for meeting the respective domain.




Cycle Project Measure Comment Status Public Comment Period
Spring 2023 Patient Safety (Meeting Summary) Closed -
Spring 2023 Patient Safety 3636 - Quarterly Reporting of COVID-19 Vaccination Coverage among Healthcare Personnel Closed -
Spring 2023 Patient Safety 3687e - ePC-07 Severe Obstetric Complications Closed -
Spring 2023 Patient Safety 3728 - Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) Closed -
Spring 2023 Patient Safety 3746 - Avoid Hospitalization After Release with a Misdiagnosis—ED Stroke/Dizziness (Avoid H.A.R.M.—ED Stroke/Dizziness) Closed -
Spring 2023 Patient Safety 3749e - Diagnostic Delay of Venous Thromboembolism (DOVE) in Primary Care Closed -
Spring 2023 Prevention and Population Health (Meeting Summary) Closed -
Spring 2023 Prevention and Population Health 3747 - Engagement in Community-Based Mental Health Care After a Mental Health Hospitalization Closed -
Spring 2023 Prevention and Population Health 3748 - Quality of Care Composite for Implantable Cardioverter-Defibrillator (ICD)/Cardiac Resynchronization Therapy Defibrillator (CRT-D) Closed -
Spring 2023 Prevention and Population Health 3751 - Risk Adjusted Post-Ambulance Provider Triage Emergency Department (ED) Visit Rate Measure Closed -
Spring 2023 Primary Care and Chronic Illness (Meeting Summary) Closed -
Spring 2023 Primary Care and Chronic Illness 3210e - HIV viral suppression Closed -
Spring 2023 Primary Care and Chronic Illness 3742 - ESRD Dialysis Patient Life Goals Survey (PaLS) Closed -
Spring 2023 Primary Care and Chronic Illness 3752e - HIV Annual Retention in Care Closed -
Spring 2023 Primary Care and Chronic Illness 3753 - Delay in Progression of Chronic Kidney Disease (CKD) Measure Closed -
Spring 2023 Primary Care and Chronic Illness 3754 - Risk Standardized Mortality Ratio for Late-Stage Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) Closed -
Spring 2023 Primary Care and Chronic Illness 3755e - STI Testing for People with HIV Closed -
Fall 2022 All-Cause Admissions and Readmissions (Meeting Summary) Closed -
Fall 2022 Cardiovascular (Meeting Summary) Closed -
Fall 2022 Geriatrics and Palliative Care (Meeting Summary) Closed -
Fall 2022 Patient Experience and Function (Meeting Summary) Closed -
Fall 2022 Patient Safety (Meeting Summary) Closed -
Fall 2022 Prevention and Population Health (Meeting Summary) Closed -
Fall 2022 Renal (Meeting Summary) Closed -