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Endorsement & Maintenance

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. 

Measure Evaluation

Our E&M process consists of 6 major stages occurring within 6 months, starting with Intent to Submit and cascading to the appeals period. Below we outline the measure evaluation stages for each E&M cycle (Fall or Spring).  

During each stage, we work closely with developers and stewards, committee members, and other interested parties to address questions regarding the E&M process and the PQM Measure Evaluation Rubric. We also conduct the endorsement meetings and provide all relevant materials and documentation of the endorsement deliberations and decisions, including committee rationales. We inform all interested parties of the status of measures going through the process and welcome public comment on the measures and endorsement decisions throughout the review cycle. Lastly, all information pertaining to the E&M committee meetings, the measures being reviewed, and the E&M meetings themselves are made public. 

 

  • Description:
    Measure developers/stewards submit key measure information to Battelle (e.g., description, numerator, denominator) via the PQM website. 
     
  • Timing:
    October 1* and April 1*   
    * If the deadline ends on a weekend or holiday, the deadline will be the next immediate business day.

  • Description:
    Measure developers/stewards submit full measure information to Battelle (e.g., specifications, testing, supportive evidence) via the PQM website.
     
  • Timing:
    November 1* and May 1*
    * If the deadline ends on a weekend or holiday, the deadline will be the next immediate business day.

  • Description:
    Full measure information is posted to PQM website for public comment. During this time, any interested party may submit a public comment via the PQM website or attend our virtual Public Comment Listening Sessions to share a comment verbally. We also convene the Advisory Groups of each E&M committee virtually to provide feedback and ask questions for the developer. All public comments, Advisory Group feedback and questions, and developer/steward responses are shared publicly and with the Recommendation Group for endorsement consideration. The E&M team also conducts preliminary assessments of the submitted measures, which are posted to the respective measure pages on the PQM website.
     
  • Timing:
    Public comment is open for 30 days, 1-2 months prior to the endorsement meetings. Public Comment Listening Sessions and Advisory Group meetings are conducted during this 30-day period.

  • Description: 
    Recommendation Group members conduct an independent review of their respective E&M committee’s measures and assign preliminary ratings (e.g., Met, Not Met, but Addressable, Not Met) for each domain of the PQM Measure Evaluation Rubric. 
  • Timing: 
    At least 3 weeks prior to the endorsement meetings.

  • Description:
    The Recommendation Group meets to discuss and share perspectives regarding the measures under endorsement review for their respective E&M committee. Recommendation Group members also consider comments from the public and the Advisory Group, developer responses, and the E&M team preliminary assessments. Endorsement voting occurs during these virtual meetings and will reside with the Recommendation Group only.
     
  • Timing:  
    July/August (Fall cycle) and January/February (Spring cycle)

  • Description:
    Endorsement decisions rendered by the Recommendation Groups are posted to PQM website for the appeals period. Any interested party may submit an appeal for any endorsement decision and must meet the eligibility criteria to be considered by the Appeals Committee (see Appeals Eligibility Criteria in the E&M Guidebook for more information). The Appeals Committee, which consists of the co-chairs of all 5 E&M committees, review eligible appeals, and vote to either maintain or overturn the endorsement decision. After the appeals period and any consideration of an appeal, a final report is published for each of the five E&M projects that summarizes the measure review process and meetings for that given E&M cycle.
     
  • Timing:  
    The appeals period is open for 3 weeks. Any eligible appeal will be considered within 2 weeks after the close of the appeals period. Final reports for each E&M project are published to the PQM website in October (Spring cycle) and April (Fall cycle).

 

Next Steps After Endorsement 

Once a measure is endorsed, it will enter a 5-year maintenance cycle, at which time the measure is resubmitted to Battelle for PQM endorsement review. Prior to the 5-year maintenance review, there are several opportunities for measure stewards to report changes to the measure specification:

  1. Annual Updates: Measure developers/stewards have the option to submit an annual update of the measure specifications to Battelle. This report either reaffirms the measure specifications remain the same as those at the time of endorsement or last update or outline any changes or updates made to the endorsed measure, including the purpose for the changes.
     
  2. Three Year Status Update: At 3-years since the measure’s endorsement, developers/stewards provide a status report indicating whether any changes to the measure specifications are needed. The developer/steward may also attest if no changes are required. Once the 3-year status report is submitted, we will review to confirm if any indicated changes require the measure to be submitted for endorsement review before the 5-year maintenance cycle. 
     
  3. Ad Hoc Status Update: If changes occur to a measure at any time in between the measure’s last endorsement review and its scheduled maintenance endorsement review, the measure steward is responsible for informing Battelle immediately by submitting a status report. An early maintenance review is conducted if the changes materially affect the measure’s original concept or logic (see Emergency/Off-Cycle Review section of the E&M Guidebook for more information).