CMS-10394 QECP Measure Information Workbook

OMB No. 0938-1144
Exp. 04/30/2015

Measure Information Workbook
Instructions for QEs Preparing Evidence for the Phase 3 Minimum Requirements Review
The purpose of this workbook is to provide QEs with a comprehensive and concise workbook for submitting all required measure-specific
evidence for QECP Standards 4 and 5. Use this workbook to describe the performance measures that your organization plans to include in its
QE provider performance reports. Please submit measures for review only if they pass all reliability and validity tests and were:
(a) calculated using Medicare data obtained through QECP Certification; or
(b) calculated using your entities' public QE performance reports.
This instructions page is divided into three sections:
► General Instructions for Completing and Uploading the Workbook
► Standard Measure Worksheet Codebook
► Alternative Measure Worksheet Codebook

General Instructions for Completing and Uploading the Workbook
1.

Save a copy of this workbook locally to your computer or network drive and work off of your local copy.

2.

If your organization plans to include more than 30 measures in its QE performance reports (inclusive of standard and alternative
measures), you must complete the following 2-step process. Otherwise, skip this step and proceed to Step 3 below.
► Step 2.1: Several weeks prior to your submission of Phase 3 evidence, complete the worksheet in the "GT30 List of All Measures"
tab and submit to your QECP Program Manager.
► Step 2.2: The QECP team will select a sample of measures for which the QE will be responsible for submitting all evidence
outlined in the Standard and Alternative Measure Worksheets. For those measures not included in the sample, no evidence or
supporting documentation will be required to be reported in the standard and alternative measure worksheets, or uploaded to the
application portal; however the QE will be required to attest that these non-sampled measures meet the requirements for all
elements under QECP Standards 4 and 5.

3.

Enter data into the worksheets following the standard and alternative measure codebooks described below. Note that some columns
restrict your data entry to selections from a drop-down menu.
► For the columns that require detailed narratives (cells shaded in gray in the worksheets), you must indicate the file name,
page number(s), and section(s) of the supporting document that include the required information.
► Blank values are not permitted. In the few instances where a column is not applicable to a particular measure, enter
"N/A" and describe why this column is not applicable to the measure.

4.

Save the workbook as "QECP_Measure_Information_Workbook_QEName.xlsx," and upload it to your organization's secure QECP
application portal.
► This workbook should only be uploaded to your entity's QECP application portal once. Since the evidence contained in this
workbook applies to all elements (4A - 4H) under Standard 4, and possibly both elements (5A - 5B) under Standard 5, use the
"Select Document" drop-down menu to associate this workbook with each relevant element.
► In the "Self Assessment" comment box for Element 5A and 5B, briefly describe the suite of provider performance measures
submitted for review, including the total number of Standard (5A) and/or Alternative (5B) measures.

5.

Upload all supporting documentation referenced in this workbook. Please note that the supporting documents uploaded to the
application portal must map back to the file names referenced in this workbook.

Standard Measure Worksheet Codebook
There are twenty-nine (29) columns to complete in the tab titled "Standard Measure Worksheet." Complete this worksheet, entering
only one measure in each row, based on the following instructions.
NQF Number
(or QE CBEC
Measure ID)
(5A)

Enter the NQF assigned number of the calculated measure. If the measure is an approved by a Consensus
Based Entity (CBE) certified under the Qualified Entity Medicare Data Sharing Program, enter the
measure's QE CBEC ID. If the measure is not an NQF-endorsed measure or a QE CBEC endorsed
measure, but is still considered "standard" under the QE program, please leave this field blank.
NOTE: For a measure to be considered as Standard under the Qualified Entity Certification
Program, the measure MUST meet at least one of the following criteria: 1) NQF-endorsed, 2)
currently being used in a CMS program that includes quality measurement or 3) authored by
an approved Consensus Based Entity (CBE). The entity must follow the measure
specifications as written , including all numerator and denominator inclusions and
exclusions, measured time periods and specified data sources. The QECP reviews the
organization's specifications against the source specification and determines whether the
measure meets the requirements.

Measure Name
(5A)

Enter the name of the standard measure. If the measure does not have an NQF-endorsed title you may
use the name of the measure steward and the title they have assigned.

Measure Steward
(5A)

Use the drop-down menu to select the measure steward: CMS, AHRQ, AQA, NCQA, TJC, AMA PCPI,
Specialty Medical Boards, or Other.

If Other, Name of
Measure Steward
(5A)

If the measure steward does not appear in the drop-down menu, type the name here.

Measure
Description
(5A)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a
description of each measure.

Type of Provider
Measured
(5A)

Use the drop-down box to select the type of provider or supplier measured: Physician, Other Health Care
Practitioners, Hospitals, Critical Access Hospitals, Skilled Nursing Facilities, Comprehensive Outpatient
Rehabilitation Facilities, Home Health Agencies, Hospice Programs, or Other.

Measure Selection
Rationale
(5A)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the
measure selection rationale for each measure.

QECP Measure Information Workbook
Instructions

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Enter the name of the file, relevant page number(s), and section(s) of the document containing the
Relationship of
Measure to Existing relationship of each measure to other measurement efforts.
Measurement
Efforts
(5A)

Relevance of
Measure to
Population in
Covered
Geographic Area
(5A)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the
relevance of the measure to the population in the covered geographic area.

Measure
Specification
(4A)

Enter either the name of the file, relevant page number(s), and section(s) of the document containing the
measure steward's measure specification, or provide a hyperlink or URL to the measure steward's
measure specification. A hyperlink/URL is preferred, but a document is also sufficient.

Measure
Specification for
Implementation
(4A)

If different from the measure steward’s specification, enter either the name of the file, relevant page
number(s), and section(s) of the document containing the measure specification for implementation, or
provide a hyperlink or URL to the measure specification for implementation. A hyperlink/URL is preferred,
but a document is also sufficient.

Clinical Logic
(4A)

Enter the clinical logic for the measure (e.g., denominator eligibility, numerator eligibility, exclusion criteria),
or the name of the file, relevant page number(s), and section(s) of the document containing the measure's
clinical logic.

Construction Logic Enter the construction logic for the measure (e.g., trigger start dates, temporal parameters), or the name of
the file, relevant page number(s), and section(s) of the document containing the measure's construction
(4A)
logic.
System
Reports/Logs
(4A)

Enter the name of the file, relevant page number(s), and section(s) of the document containing system
input/output reports/logs for each measure that displays data sources, exclusion statements, denominator
values, and numerator values.

Attribution
Methodology
(4B)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a
description of the methodology used for each measure to assign patients and/or episodes to the provider
included in the performance reports.

Measure Type
(4C & 4D)

Use the drop-down menu to select the measure type: Quality, Effectiveness, Efficiency, or Resource Use.

Minimum
Requirements for
Reporting Quality
Measures
(4C)

Enter the minimum requirements for reporting each quality measure that incorporates Medicare data (e.g.,
sample/denominator size, confidence interval, or reliability score).

Results of
Statistical Validity
Testing
(4C)

Enter the results of statistical validity testing for each quality measure to be included in QE performance
reports, including the actual sample/denominator size, confidence interval, or reliability score.

Minimum
Requirements for
Reporting
Efficiency,
Effectiveness, and
Resource Use
Measures
(4D)

Enter the minimum requirements for reporting each efficiency, effectiveness, and resource use measure
that incorporates Medicare data (e.g., sample/denominator size, confidence interval, or reliability score).

Results of
Statistical Validity
Testing
(4D)

Enter the results of statistical validity testing for each efficiency, effectiveness, and resource use measure,
including the actual sample/denominator size and at least one of the following: reliability score, or
confidence interval.

Risk Adjustment
Rationale
(4E)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a detailed
rationale for using or not using risk adjustment for each measure. If risk adjustment was not used, the QE
must include a detailed justification.

Risk Adjustment
Methodology
(4E)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the
methodology used for risk adjustment for each measure (including case-mix or severity adjustment).

Outlier Method
Rationale
(4F)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a detailed
rationale for using or not using an outlier method for each measure. If an outlier method was not used, the
QE must include a detailed justification.

Outlier
Methodology
(4F)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the outlier
methodology used for each measure.

QECP Measure Information Workbook
Instructions

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Peer Group
Algorithm
(4G)

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
algorithm used to identify peer groups for each measure.

Peer Group
Geographic
Parameters
(4G)

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
geographic parameters that were used to compare providers to their peers for each measure.

Benchmark
Identification
(4H)

Enter the name of the file, relevant page number(s), and section(s) of the document describing how the
benchmark was identified or estimated (e.g., external data source, current data set) for each measure.

Type of Benchmark Enter the name of the file, relevant page number(s), and section(s) of the document describing the type of
benchmark (e.g., 90th percentile, national average, regional average) for each measure.
(4H)

Geographic
Parameters for
Benchmark
(4H)

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
geographic parameters that were used to identify benchmarks for each measure.

Alternative Measure Worksheet Codebook
There are twenty-eight (28) columns to complete in the tab titled "Alternative Measure Worksheet." Complete this worksheet,
entering only one measure in each row, based on the following instructions.
Measure Name
(5B)

Enter the name of the alternative measure. If the measure does not have an NQF-endorsed title you may
use the name of the measure steward and the title they have assigned.

Measure Steward
(5B)

Use the drop-down menu to select the measure steward: CMS, AHRQ, AQA, NCQA, TJC, AMA PCPI,
Specialty Medical Boards, or Other.

If Other, Name of
Measure Steward
(5B)

If the measure steward does not appear in the drop-down menu, type the name here.

Measure
Description
(5B)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a
description of each measure.

Type of Provider
Measured
(5B)

Use the drop-down box to select the type of provider or supplier measured: Physician, Other Health Care
Practitioners, Hospitals, Critical Access Hospitals, Skilled Nursing Facilities, Comprehensive Outpatient
Rehabilitation Facilities, Home Health Agencies, Hospice Programs, or Other.

Evidence of
Superiority to
Standard Measure
(5B)

Enter the name of the file, relevant page number(s), and section(s) of the document providing evidence
that the measure is more valid, reliable, responsive to consumer preferences, cost effective, or relevant to
dimensions of quality and resource use not addressed by a standard measure.

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
Relationship of
Measure to Existing relationship of the measure to existing measurement efforts.
Measurement
Efforts (5B)

Relevance of
Measure to
Population in
Covered
Geographic Area
(5B)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the
relevance of the measure to the population in the covered geographic area.

Measure
Specification
(4A)

Enter either the name of the file, relevant page number(s), and section(s) of the document containing the
measure steward's measure specification, or provide a hyperlink or URL to the measure steward's
measure specification. A hyperlink/URL is preferred, but a document is also sufficient.

Measure
Specification for
Implementation
(4A)

If different from the measure steward’s specification, enter either the name of the file, relevant page
number(s), and section(s) of the document containing the measure specification for implementation, or
provide a hyperlink or URL to the measure specification for implementation. A hyperlink/URL is preferred,
but a document is also sufficient.

Clinical Logic
(4A)

Enter the clinical logic for the measure (e.g., denominator eligibility, numerator eligibility, exclusion criteria),
or the name of the file, relevant page number(s), and section(s) of the document containing the measure's
clinical logic.

Construction Logic Enter the construction logic for the measure (e.g., trigger start dates, temporal parameters), or the name of
the file, relevant page number(s), and section(s) of the document containing the measure's construction
(4A)
logic.
System
Reports/Logs
(4A)

QECP Measure Information Workbook
Instructions

Enter the name of the file, relevant page number(s), and section(s) of the document containing system
input/output reports/logs for each measure that displays data sources, exclusion statements, denominator
values, and numerator values.

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Attribution
Methodology
(4B)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a
description of the methodology used for each measure to assign patients and/or episodes to the provider
included in the performance reports.

Measure Type
(4C & 4D)

Use the drop-down menu to select the measure type: Quality, Effectiveness, Efficiency, or Resource Use.

Minimum
Requirements for
Reporting Quality
Measures
(4C)

Enter the minimum requirements for reporting each quality measure that incorporates Medicare data (e.g.,
sample/denominator size, confidence interval, or reliability score).

Results of
Statistical Validity
Testing
(4C)

Enter the results of statistical validity testing for each quality measure to be included in QE performance
reports, including the actual sample/denominator size, confidence interval, or reliability score.

Minimum
Requirements for
Reporting
Efficiency,
Effectiveness, and
Resource Use
Measures
(4D)

Enter the minimum requirements for reporting each efficiency, effectiveness, and resource use measure
that incorporates Medicare data (e.g., sample/denominator size, confidence interval, or reliability score).

Results of
Statistical Validity
Testing
(4D)

Enter the results of statistical validity testing for each efficiency, effectiveness, and resource use measure,
including the actual sample/denominator size and at least one of the following: reliability score, or
confidence interval.

Risk Adjustment
Rationale
(4E)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a detailed
rationale for using or not using risk adjustment for each measure. If risk adjustment was not used, the QE
must include a detailed justification.

Risk Adjustment
Methodology
(4E)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the
methodology used for risk adjustment for each measure (including case-mix or severity adjustment).

Outlier Method
Rationale
(4F)

Enter the name of the file, relevant page number(s), and section(s) of the document containing a detailed
rationale for using or not using an outlier method for each measure. If an outlier method was not used, the
QE must include a detailed justification.

Outlier
Methodology
(4F)

Enter the name of the file, relevant page number(s), and section(s) of the document containing the outlier
methodology used for each measure.

Peer Group
Algorithm
(4G)

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
algorithm used to identify peer groups for each measure.

Peer Group
Geographic
Parameters
(4G)

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
geographic parameters that were used to compare providers to their peers for each measure.

Benchmark
Identification
(4H)

Enter the name of the file, relevant page number(s), and section(s) of the document describing how the
benchmark was identified or estimated (e.g., external data source, current data set) for each measure.

Type of Benchmark Enter the name of the file, relevant page number(s), and section(s) of the document describing the type of
benchmark (e.g., 90th percentile, national average, regional average) for each measure.
(4H)

Geographic
Parameters for
Benchmark
(4H)

QECP Measure Information Workbook
Instructions

Enter the name of the file, relevant page number(s), and section(s) of the document describing the
geographic parameters that were used to identify benchmarks for each measure.

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List of ALL QECP Measures Template
Note: QEs are only required to complete this worksheet if they intend to include more than 30 measures in their QE performance reports
(inclusive of standard and alternative measures). Refer to Step 2 in the "Instructions" tab.

Row #

Standard or Alternative
QECP Measure
[select from menu]

NQF Number
(or QE CBEC
Measure ID)

Measure Name

Measure Steward
[select from menu]

If Other, Name of
Measure Steward

Measure Description

Type of Provider Measured
[select from menu]

Measure Type
[select from menu]

Clinical Logic

Construction Logic

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QECP Measure Information Workbook
GT30 List of All Measures

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List of ALL QECP Measures Template
Note: QEs are only required to complete this worksheet if they intend to include more than 30 measures in their QE performance reports
(inclusive of standard and alternative measures). Refer to Step 2 in the "Instructions" tab.

Row #

Standard or Alternative
QECP Measure
[select from menu]

NQF Number
(or QE CBEC
Measure ID)

Measure Name

Measure Steward
[select from menu]

If Other, Name of
Measure Steward

Measure Description

Type of Provider Measured
[select from menu]

Measure Type
[select from menu]

Clinical Logic

Construction Logic

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QECP Measure Information Workbook
GT30 List of All Measures

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QECP Standard Measure Evidence For Standard 4 and Element 5A
Note: For the cells shaded in gray, QEs must indicate the file name, page number(s), and section(s) of the supporting document and
then upload the supporting document to the secure application portal.

NQF
Number
(or QE
Row #
CBEC
Measure
ID)
(5A)

Measure Name
(5A)

Measure
Steward
[select from
menu]
(5A)

If Other,
Name of
Measure
Steward
(5A)

Measure Description
(5A)

Type of
Provider
Measured
[select from
menu]
(5A)

Measure Selection Rationale
(5A)

A Hyperlink/URL is preferred; however, a document
reference is also sufficient.

Relationship of Measure to
Existing Measurement
Efforts
(5A)

Relevance of Measure to
Population in Covered
Geographic Area
(5A)

Measure Specification
(4A)

Measure Specification
for Implementation
(4A)

If the logic is simple and brief, describe here;
otherwise a document reference is sufficient.

Clinical Logic
(4A)

Construction Logic
(4A)

System
Reports/Logs
(4A)

Attribution
Methodology
(4B)

Measure Type
[select from menu]
(4C & 4D)

Minimum Requirements
for Reporting Quality
Measures
(4C)

Results of Statistical
Validity Testing
(4C)

Minimum Requirements
for Reporting Efficiency,
Effectiveness, and
Resource Use Measures
(4D)

Results of Statistical
Validity Testing
(4D)

Risk Adjustment Risk Adjustment
Rationale
Methodology
(4E)
(4E)

Outlier Method
Rationale
(4F)

Outlier
Methodology
(4F)

Peer Group
Algorithm
(4G)

Peer Group
Geographic
Parameters
(4G)

Benchmark
Identification
(4H)

Type of
Benchmark
(4H)

Geographic
Parameters for
Benchmark
(4H)

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QECP Measure Information Workbook
Standard Measure Worksheet

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QECP Alternative Measure Evidence For Standard 4 and Element 5B
Note: For the cells shaded in gray, QEs must indicate the file name, page number(s), and section(s) of the supporting
document and then upload the supporting document to the secure application portal.
A Hyperlink/URL is preferred; however, a document
reference is also sufficient.

Row #

Measure Name
(5B)

Measure
Steward
[select from
menu]
(5B)

If Other,
Name of
Measure
Steward
(5B)

Measure Description
(5B)

Type of
Provider
Measured
[select from
menu]
(5B)

Evidence of Superiority to
Standard Measure
(5B)

Relationship of Measure to
Existing Measurement
Efforts
(5B)

Relevance of Measure to
Population in Covered
Geographic Area
(5B)

Measure Specification
(4A)

Measure Specification for
Implementation
(4A)

If the logic is simple and brief, describe here;
otherwise a document reference is sufficient.

Clinical Logic
(4A)

Construction Logic
(4A)

System
Reports/Logs
(4A)

Attribution
Methodology
(4B)

Measure Type Minimum Requirements
[select from
for Reporting Quality
Measures
menu]
(4C)
(4C & 4D)

Results of Statistical
Validity Testing
(4C)

Minimum Requirements
for Reporting Efficiency,
Effectiveness, and
Resource Use Measures
(4D)

Results of Statistical
Validity Testing
(4D)

Risk Adjustment Risk Adjustment
Rationale
Methodology
(4E)
(4E)

Outlier Method
Rationale
(4F)

Outlier
Methodology
(4F)

Peer Group
Algorithm
(4G)

Peer Group
Geographic
Parameters
(4G)

Benchmark
Identification
(4H)

Type of
Benchmark
(4H)

Geographic
Parameters for
Benchmark
(4H)

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QECP Measure Information Workbook
Alternative Measure Worksheet

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