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CMS explains QCDR measure requirements, testing expectations and common reasons for rejection
Summary
CMS presenters advised measure owners that measures must be beyond concept stage, show a performance gap, be tested (face validity first year; more testing thereafter), and avoid duplication; borrowed/co‑owned measures require permissions and documentation.
Marlene of the Pickums team explained that QCDR measures must be beyond the concept stage and supported by performance data collected prior to self‑nomination. "QCDR measures should be beyond the measure concept phase of development. The measure should address significant variation in performance," she said.
Marlene urged a preference for outcome‑based measures and walked through testing requirements: first‑year measures require face validity testing, while subsequent years must include measure‑score reliability and validity testing plus encounter‑level data when applicable. She warned CMS may reject measures that duplicate current or retired measures, lack evidence of a performance gap, are topped‑out, or have low adoption. QCDRs borrowing measures must upload permission documents at self‑nomination; co‑owned measures must list co‑owners and designate stewardship in the form.
