Aligning Quality Measures Across CMS - the Universal Foundation

To further the goals of the CMS National Quality Strategy, CMS leaders from across the Agency have come together to streamline quality measures across CMS quality programs for the adult and pediatric populations. This “Universal Foundation” of quality measures will focus provider attention, reduce burden, identify disparities in care, prioritize development of interoperable, digital quality measures, allow for cross- comparisons across programs, and help identify measurement gaps. The development and implementation of the Preliminary Adult and Pediatric Universal Foundation Measures will promote the best, safest, and most equitable care for individuals as we all work together on these critical quality areas. As CMS moves forward with the Universal Foundation, we will be working to identify foundational measures in other specific settings and populations to support further measure alignment across CMS programs as applicable.

Selection Criteria for the Universal Foundation:

• The measure is of a high national impact
• The measure can be benchmarked nationally and globally
• The measure is applicable to multiple populations and settings
• The measure is appropriate for stratification to identify disparity gaps
• The measure has scientific acceptability
• The measure is feasible and computable (or capable of becoming digital)
• The measure has no unintended consequences

These measures will be used across CMS quality programs and prioritized for stratification and digitization. The CMS Center for Medicare & Medicaid Innovation (CMMI) retains the role to test new and innovative measures.

Universal Foundation:

Adult

Domain	Measure Identification Number and Name
Wellness and prevention	139: Colorectal cancer screening 93: Breast cancer screening 26: Adult immunization status
Chronic conditions	167: Controlling high blood pressure 204: Hemoglobin A1c poor control (>9%)
Behavioral health	672: Screening for depression and follow-up plan 394: Initiation and engagement of substance use disorder treatment
Seamless care coordination	561 or 44: Plan all-cause readmissions or all-cause hospital readmissions
Person-centered care	158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)
Equity	Identification number undetermined: Screening for social drivers of health

Pediatric

Domain	Measure Identification Number and Name
Wellness and prevention	761 and 123: Well-child visits (well-child visits in the first 30 months of life; child and adolescent well-care visits) 124 and 363: Immunization (childhood immunization status; immunizations for adolescents) 760: Weight assessment and counseling for nutrition and physical activity for children and adolescents 897: Oral evaluation, dental services
Chronic conditions	80: Asthma medication ratio (reflects appropriate medication management of asthma)
Behavioral health	672: Screening for depression and follow-up plan 268: Follow-up after hospitalization for mental illness 264: Follow-up after emergency department visit for substance use 743: Use of first-line psychosocial care for children and adolescents on antipsychotics  271: Follow-up care for children prescribed attention deficit-hyperactivity disorder medicine
Person-centered care	158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)

Add-ons:

To assess care provided to specific populations and settings (es. Hospital-based care or maternity care) additional measures beyond those captured in the Adult and Pediatric Universal Foundation are necessary. As with the Adult and Pediatric Universal Foundation measures, CMS will identify add-on measures to be implemented consistently across applicable programs. However, a particular measure may be essential to assess care, but only be appropriate for one program. CMS will continue developing more add-on sets in 2024, including one for behavioral health.

Hospital

Domain	Measure Identification Number and Name
Chronic Conditions Equity	696: Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure  1664: Screening for Social Drivers of Health
Person-Centered Care	338: Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey 162: Outpatient and Ambulatory Surgery CAHPS Survey
Safety	460: National Healthcare Safety Network (NHSN) Central Line Associated Bloodstream Infection (CLABSI) Outcome Measure 459: NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure 463: NHSN Facility-Wide Inpatient Hospital-onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure 1: NHSN Surgical Site Infection (SSI) 462: NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure 135: Patient Safety Indicators (PSI) 90 678: Severe Sepsis and Septic Shock Management Bundle 1633: Severe Obstetric Complications
Seamless care coordination	356: Hybrid Hospital-Wide All-Cause Readmission  427: Median Time from ED Arrival to ED Departure for Discharged ED Patients

Post-acute Care

Domain	Measure Identification Number and Name
Behavioral Health	522: Percent of Residents Who Have Symptoms of Depression (Long Stay)
Person-Centered Care	1698: Discharge Function Score 154: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey
Safety	225: Drug Regimen Review Conducted with Follow-Up for Identified Issues-PAC  520: Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay) 680: Skilled Nursing Facility Healthcare-Associated Infections (SNF HAI) Requiring Hospitalization  121: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury 471: Number of Hospitalizations per 1,000 Long Stay Resident Day
Seamless care coordination	575: Potentially Preventable 30-Day Post-Discharge Readmission Measure 210: Discharge to Community-Post Acute Care (PAC) 728: Transfer of Health Information to the Provider Post-Acute Care (PAC) 727: Transfer of Health Information to the Patient Post-Acute Care (PAC)

Maternity Care

Domain	Measure Identification Number and Name
Safety	418: Maternal Morbidity Structural Measure 1633: Severe Obstetric Complications (eCQM) 508: Cesarean Birth (LRCD-CH/ eCQM)
Wellness and Prevention	581: Prenatal and Postpartum Care: Postpartum Care (PPC-AD) 582: Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-CH)

The Universal Foundation: Next Steps

The Universal Foundation will continue to evolve over time:

• CMS will develop setting- and population-specific “add-on” measure sets
• Measures may be replaced or removed when goals are met
• Measures may be added to assess quality across the care journey
• CMMI will continue to test new and innovative measures

CMS will solicit feedback on the Universal Foundation through comments, rulemaking, listening sessions, or other forums.

To learn more the impact and next steps of the Universal Foundation, read ‘Aligning Quality Measures Across CMS -the Universal Foundation’ in the New England Journal of Medicine.

Send feedback to QualityStrategy@cms.hhs.gov.

Learn More

• CMS National Quality Strategy
• Meaningful Measures 2.0
• Cascade of Meaningful Measures
• Frequently Asked Questions & Tools
• Contact Us