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Measure Set Review (MSR)

Balancing Burden vs. Impact

The MSR process allows interested parties to consider the purpose of each program’s measures and weigh the impact of these measures against the burden of their implementation. 

The MSR process is statutorily enabled by the Consolidated Appropriations Act, 2021 Public Law 116–260. PQM will conduct the MSR annually to provide recommendations on the removal of quality and efficiency measures from CMS programs.


The public comment period is now open for the 2023 Measure Set Review (MSR) Draft Report and the Guidebook of Policies and Procedures for Pre-Rulemaking Measure Review (PRMR) and Measure Set Review (MSR) is ready for download.

Goals & Focus
To optimize the CMS measure portfolioAcross program, target population, and time
PRMR Overview

* Novel Hybrid Delphi and Nominal Group: This is a multi-step process increase engagement of all members and structure facilitation by using standard criteria and practices. The approach allows committees to maximize the value of the time spent by focusing discussion on measures where there is disagreement.
† MSR  consists of only a recommendation approach and follows a modified NHDNG process. 

MSR Recommendation Group

PQM identifies 20 to 25 members from across the three PRMR committees (Hospital, Clinician, and Post-Acute Care/Long-Term Care) who represent a range of experience and expertise. These individuals are invited to serve on the MSR Recommendation Group. MSR follows a modified Novel Hybrid Delphi and Nominal Group technique and does not have advisory groups. 

Modified Novel Hybrid Delphi and Nominal Group Technique for MSR

The MSR evaluation processes entail iterative measure reviews. The review process is a combination of Battelle-led assessments (Staff Assessments) and input from MSR Recommendation Group members. This multi-step process is meant to increase engagement of all members and structure facilitation by using standard criteria and practices. The MSR process allows for a more holistic review involving qualitative assessment of portfolios of measures across programs and is guided by interested parties’ input. 

MSR Process Workflow

Please contact [email protected] for more information.