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Performance Measures

Find resources on the latest quality programs and ºÚÁÏÍø®-sponsored initiatives and submit your own concepts for measurement.

Performance measures serve as a mechanism to evaluate quality and cost-of-care performance. A vital component to drive improvements, they offer the ability to objectively assess how well and appropriately healthcare is delivered when compared to recognized standards.

Call for Input on New Breast Imaging Measures

Mammography quality and cost measures are being finalized for Centers for Medicare and Medicaid Services (CMS) consideration and inclusion in the Merit-based Incentive Payment System (MIPS).

To support the delivery of high-quality, low-cost breast cancer screening, Acumen, LLC developed three quality measures and one cost measure that assess clinician performance in breast cancer screening and diagnosis.

Acumen reached out to ºÚÁÏÍø to request nominations for the measure development expert panel, which resulted in the inclusion of ACR-recommended breast imaging radiologists. Patients and other clinicians also supported the measures’ development.

ºÚÁÏÍø continues to monitor the progress of measure development and is collecting comments about the measures to provide to Acumen and eventually CMS when considered for future inclusion in the MIPS, a CMS clinician quality program.

Acumen provided summaries of the technical expert panel (TEP) meetings, which provide insight into the development of their quality and cost measures. They also provided Quality Code Lists presenting the codes that trigger an episode of care and the diagnostic follow-up services included in the Recall Rate, PPV1 and PPV3 measures. The Cost Codes List presents the qualifying codes for meeting the cost measure’s criteria.

ACR-Developed Measures

The ºÚÁÏÍø Measurement Strategy Group vets concepts, assigning high-priority measures to the ºÚÁÏÍø Metrics Committee development pipeline. Get involved as a participant or submit a new concept.

At ºÚÁÏÍø, we know great ideas often come out of hands-on experience. That’s why we’re seeking your input into developing quality measures.

You can submit your concepts for quality measures regardless of what stage they’re in, and have them reviewed by the ºÚÁÏÍø Measurement Strategy Group. Concepts meeting the criteria for high priority will be charged for development or refinement by the ºÚÁÏÍø Metrics Committee.

Measure concepts that have been developed or refined by the Metrics Committee are intended for use in the Centers for Medicare and Medicaid (CMS) Merit-based Incentive Payment System (MIPS) either through the ºÚÁÏÍø Qualified Clinical Data Registry (QCDR) or as a MIPS clinical quality measure (CQM). Both measure reporting pathways are directly linked to physician payment under CMS' MIPS regulations.

Measure concepts submitted for prioritization may address a variety of topics or include concepts for updating current MIPS measures.

  1. To start your process, navigate to the submission .
  2. Complete the required .
  3. A sample of a concept submission form for a measure that was submitted, approved and developed is .

Your radiology practice can help us develop standardized measures to be used throughout the imaging field. Interested in testing new measures currently under development by ºÚÁÏÍø at your facility?

 

DXA: Improving Diagnosis of True Changes in Bone Mineral Density

This measure aims to improve the communication quality of dual-energy X-ray absorptiometry (DXA) reports by encouraging assessment and reporting of measurement precision.

Evidence-Based Recommendations for Abdominal Aortic Aneurysm

These measures aim to ensure that evidence-based follow-up recommendations are made for abdominal aortic aneurysms (AAA) with a diameter of 2.5 cm or greater.

Closing the Recommendations Follow-Up on Actionable Incidental Findings

These measures intend to ensure the completion of evidence-based radiologist-recommended follow-up.

  • Early Adoption: Utilize these measures that support the development of a new follow-up workflow or improve an existing flow.
    • Support the measures’ potential use in accountability programs like the Centers for Medicare and Medicaid Services (CMS). ºÚÁÏÍø must acquire data demonstrating that they may be successfully implemented into programs according to their specified measurement level (e.g., physician, group, facility, or system level).
    • Implement the nine available measures. However, all measures are not required to be used to serve as an early adoption site.

      **Participation awards are available on a first-come-first-served basis.

Diagnostic Imaging Measure Set: 2018

These diagnostic imaging quality measures were finalized in May 2018.

Diagnostic Imaging Measure Set: 2017

These diagnostic imaging quality measures were finalized in June 2017.

Performance Measurement Educational Videos

Access our library of recordings to guide you through the development process below.

  • Anatomy of a Measure

  • Deep Dive on Reliability

  • Deep Dive on Validity

  • Measure Evaluation and Selection

ºÚÁÏÍø Measurement Glossary

This comprehensive guide gives you the terms and phrases used in developing quality measures for the Centers for Medicare and Medicaid Services (CMS) quality performance programs.

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