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 (Spring cycle) and January/February (Fall 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: Maintaining Endorsement
Maintenance of endorsement encompasses several processes: (1) evaluations for endorsement maintenance, (2) annual updates to measure specifications, and (3) emergency/off-cycle reviews (i.e., early maintenance review).
- Evaluations for Maintenance Endorsement: Once a measure is endorsed, it enters a 5-year maintenance cycle, at the end of which the developer/steward must resubmit the measure to Battelle for PQM endorsement review. In year three, developers/stewards must submit a status report indicating whether any material changes to the measure specifications have occurred/are needed. A status report is not required if the measure was conditionally endorsed with the requirement to return for full maintenance review at three years.
Developers/stewards may request an extension of up to 1 year (two consecutive cycles), except if the measure’s date of last endorsement has been more than 6 years. In exceptional cases where a developer/steward cannot submit the measure by the 6-year mark due to resource constraints, the developer/steward may request the measure be designated as Endorsed by Extension. Interested measure developers/stewards should review eligibility criteria in the E&M Guidebook and submit the attestation form to [email protected] for review.
- Annual Update: Measure developers/stewards have the option to submit an annual update each year or at any point when the measure is not scheduled for re-evaluation. Annual updates allow for limited changes, such as updating procedure, diagnostic, or other codes. The update should indicate whether any material changes have occurred/are needed since the last review, including the reasons for these changes.
- Emergency/Off-Cycle Review: A measure may undergo an early maintenance review prior to the scheduled cycle due to evidence of unintended consequences (emergency review) or material changes to the measure specifications (off-cycle review). 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).