CMS-10394 QECP Measure Information Workbook

QECP Measure Information Workbook
The purpose of this workbook is to provide QEs with a comprehensive and concise workbook for
submitting all required measure-specific evidence for QECP Program Requirements 3.1 and 3.2. 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 calculated using Medicare data obtained through QECP certification.
For each measure please complete:
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Whether the measure is considered Standard or Alternative under the QECP program. 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).
If NQF-Endorsed, NQF Number
Measure Name
Measure Steward
Measure Description
Type of Provider Measured
Measure Type
Measure Category
Measure Classification
Measure Previously Reported (privately or publicly) (Y/N)
o For any prevalence rates include justification for how the prevalence rate is associated
to a Standard or Alternative measure
For each Standard measures
o Measure Selection Rationale
o Relationship of Measure to Existing Measurement Efforts
o Relevance of Measure to Population in Covered Geographic Area
o Measure Specification
o Measure Category [select from menu]
o Statistical Validity
o Attribution Methodology
o Risk Adjustment Used
o Risk Adjustment Rationale
o Risk Adjustment Attestation
o Outlier Method Used
o Outlier Method Rationale
o Outlier Method Attestation
o Comparison Groups Algorithm
o Comparison Group Geographic Parameters
o Type of Benchmark
o Benchmark Identification
o Provider Ratings Methodology

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For each Alternative measures
o Evidence of Superiority to Standard Measure
o Relationship of Measure to Existing Measurement Efforts
o Relevance of Measure to Population in Covered Geographic Area
o Measure Specification
o Measure Specification for Implementation
o Clinical Logic
o Construction Logic
o System Reports/Logs
o Minimum Requirements for Reporting Quality Measures
o Results of Statistical Validity Testing for Quality Measures
o Minimum Requirements for Reporting Efficiency or Resource Use Measures
o Results of Statistical Validity Testing for Efficiency or Resource Use Measures
o Description of the standardized payment or pricing approach, if appropriate
o Construction of the Composite
o Minimum Requirements for Reporting Composite Measures
o Attribution Methodology
o Risk Adjustment Used
o Risk Adjustment Rationale
o Risk Adjustment Methodology
o Outlier Method Used
o Outlier Method Rationale
o Outlier Methodology
o Comparison Group Algorithm
o Comparison Group Geographic Parameters
o Benchmark Identification
o Type of Benchmark
o Provider Ratings Methodology
End of Phase 3 QECP Measure Information Workbook Requirements