MAP PAC LTC and Hospital Joint MUC List Review Meeting 2020-2021

becky and team can you all hear me this is sherry yes i guess we can hear you sherry thank you appreciate it okay um well uh good morning and welcome everyone i have 10 a.m eastern here and welcome to today’s meeting which is uh the map hospital work group meeting for pac ltc uh and also hospital um today there’s a there’s a joint meeting uh this morning we’ll have a joint session between both work groups to talk about process and overview of the map process and evaluation but we also will be talking about some of the recent measures that have come through for map consideration which are the coven 19 measures and so to be presentation for that today um and just to note that we will then break off into separate uh work group rooms or zoom rooms which those there’s links attached within the calendar invites as well as within the agendas that were distributed to you all um so those will be separate work group meeting rooms zoom rooms but today this morning we’ll be having this join meeting for the for the morning so my name is matthew pickering uh i am the nqf senior director here and overseeing the map hospital work group and it’s a pleasure uh to speak with you all today and and working on this exciting work around some of the measures coming through this cycle uh for consideration uh within cms programs i’d also like to allow my colleague amy moyer to introduce herself um as part of being pac ltc amy good morning everyone and welcome we appreciate you taking your monday to spend with us i am amy moyer the director on matt pack ltc project here at nqf and i’m really looking forward to today’s meeting thank you all i’ll turn it back to matt great thanks uh and if becky if you could go back to the housekeeping slides i’ll just touch on that really quick thank you okay um just a few housekeeping items just you know keep in mind before we get started so um we are using zoom but we asked to mute your computer or if you’re dialing through the phone to mute your line if you’re not speaking just to prevent any background noise ensure that your name is also displayed correctly in the in the box that shows um on on our on the platform or if you are dialing in you might be able to indicate who you are as well if you’re not able to put your name into the the feature within the zoom platform we can encourage you to turn on your video it is optional but we are encouraging you to turn on the video especially when you’re talking uh just allows increased engagement with folks we’d love to see your face as well just to see see everyone since we are all in a virtual environment and you can do this by right clicking on view at the right upper hand side of the the screen and go to speaker or gallery to do so uh you can use the raise a hand feature as well if you wish to provide any points or raise a question um there’s also the chat box as well you can indicate any uh questions you have within our chat box which will be monitored as well um and then for for for this meeting we will again be using zoom but for the voting procedures that will occur during our separate work group meetings in the afternoon we have the poll everywhere link which was also distributed within the calendar invite but also email communications as well we kindly ask that you do not distribute that poll everywhere link

this is only given to work group members for voting on the measures moving forward i’m going to go to the agenda and just again a reminder that this is a joint meeting in the morning in which we’re doing welcome and introductions as well as disclosures of interest and reviewing the meeting objectives we also have cms dr michelle schreiber providing some opening remarks related to the meaningful measures update and work there and then we’ll have an overview of the pre-rule making approach as well as a presentation from cms on covet 19 measures the measures that are coming through review this cycle and also an opportunity for the work groups to provide to have some questions and answers we’ll then have lunch about about 30 minutes or so from 12 30 to 1 we’ll have that break for everyone to grab lunch and then reconvene we ask you to reconvene a little bit early through zoom just to make sure that everybody’s up and running right before one o’clock and then we’ll proceed with the program measure reviews for our separate work groups as well as providing opportunity for public comment and then the summary of the day next steps and then a journey next slide please so i’d like to also allow others from the nqf staff to introduce themselves and also provide some opening remarks as well i kindly would like to introduce chris querum who’s our new interim ceo here at nqf as well as sherry winsburg who’s our senior vice president of quality measurement here at nqf to kindly introduce themselves and also provide some welcoming remarks so i’ll turn it over to chris thank you man appreciate that and welcome everyone i’ll add my thanks to those from amy for all of you who are taking time from your busy schedules to join us today i want to also acknowledge that this has been an unprecedented period of time for the map and its work groups it’s required a considerable amount of flexibility on everybody’s part to accomplish the important work of the work group and to schedule this meeting today so i very much appreciate it this is the 10th year that the national quality forum has served as the convener and the facilitator of the measures application partnership during that time we have successfully stewarded over 1 000 measures since the initial convening in 2011 and so we have a robust history of work uh to build on in our session today um the nqf’s work with the measures application partnership would not be possible without the strong support of our partners at cms and i’d like to be sure to express our appreciation to michelle and her many colleagues at the agency for their continued confidence in the nqf as the convener and the facilitator of the of the map for all these years so matt i will stop there and invite my colleague sherry to add her remarks and look forward to a very productive day with both work groups thank you thank you chris i really appreciate that this is sherry winspur i’m the senior vice president for quality measurement at the national quality forum and we very much welcome all of you here today we’re are excited to finally get some of this kicked off and make some wonderful recommendations to cms and i wanted to just kind of provide a few remarks around um i know that this year we we obviously have some changes in the timing and the format this year but our purpose really does remain the same as in any other year for map um to provide cms feedback from the lens of consumers and our provider stakeholder groups to inform the rule making process for cms quality and performance programs we’re definitely convening as chris mentioned in the midst of a national health care crisis our nation’s resources have been stretched as we face the challenges that covet has certainly presented to all of us and now with two viable vaccinations on the market and i don’t know by now maybe there’s a third one but we look forward to a future where we can prospectively overcome this crisis map will discuss the role that measurement and accountability should play related to covid vaccination among other very critical measurement issues for our patients across the united states thank you again to i will echo chris’s thank you to cms and our partners and colleagues for your preparation and your partnership on the measures applications partnership as well the cms continues to set the right tone for these meetings and again they’re they’re here today to participate with you all as well so welcome thank you so much to the

committee for all of your time as i know this takes a lot of time out of particularly today but also in preparation and looking at materials and we very much value your expertise and your input i’ll turn it back to you matt great thank you sherry and thank you chris as well uh for those opening remarks i i’ll just echo uh our gratitude to you all for all of your time uh we recognize this is a full day and also the materials uh leading up to today and reviewing those and we appreciate all of your input and engagement and participation if you do have to step away please make sure to notify your respective work groups just allows us to keep track of quorum as you know voting that goes on throughout these work group meetings as required for them so please uh just let your respective work groups know uh that you’ll have to step away at any point in time understanding that other priorities exist for everyone here so thank you very much next slide please i would like to now um turn it over to michael haney she is our senior managing director here at within quality measurement here at nqf and michael haney would introduce yourself please and also i will be doing roll call and disclosures of interest for both the work groups michael morning everyone my name is michael haney i’m a senior managing director here at nqf and very pleased to be with you this morning um before we get started i did want to offer our co-chairs the opportunity to introduce themselves so uh jerry and kurt would you like to begin i’d be delighted to michael i’m jerry lamb i’m one of the co-chairs for matt for the map post acute long-term care group and welcome everybody good morning and um i’m assuming michael will move into other welcomes in a bit after we do the um the vote the the um check-ins yes and this this is kurt mckells good morning everyone appreciate uh nqf cms uh for uh hosting and having our availability and look forward to the discussion thank you everyone thank you so much all right so what we’re going to do we’re going to do uh our um sort of roll call and disclosures all together here so uh please bear with me before we begin i would just like to give everyone a very brief reminder nqf is a non-partisan organization so out of mutual respect for each other we kindly encourage that we make an effort to refrain from making comments innuendos or humor relating to for example race gender politics or topics that otherwise might be considered inappropriate during the meeting we encourage discussions that are open constructive and collaborative so let’s all be mindful of how our language and opinions may be perceived by others we’ll combine our disclosure with the introductions and the disclosure of interests are going to be in two parts uh for each of the groups here today because we have two types of map members organizational members and subject matter experts so i’m going to start with our organizational members from pac ltc um organizational members represent the interests of a particular organization so we expect you to come to the table representing those interests because of your status as an organizational representative we ask that you only one question specific to you as an individual so we ask you to disclose if you have an interest of ten thousand dollars or more in an entity that is related to the work of this committee so now let’s start going around our virtual table it’s a very large virtual table this morning beginning with our organizational members only please um i’ll call on anyone in the meeting who is an organizational member so when i call your organization’s name please unmute your line state your name state your role in your organization and anything you wish to disclose if you don’t have anything to disclose uh please just after stating your name and title add you have nothing to disclose so we can make sure we get that documented so um uh beginning here uh the amda society for post-acute and long-term care medicine all right and if you are having trouble with mute just raise your hand um some staff can help you out and we’ll come back to that um american academy of physical medicine and rehabilitation good morning my name is kurt hoppe and i’m past president of the american academy of pm r and i have nothing to disclose thank and available a member of the quality

advisory committee for aota and i have nothing to disclose thank you american physical therapy association hello my name is alice bell i’m a senior payment specialist with the american physical therapy association and a physical therapist and i have nothing to disclose thank you atw health solutions good morning desiree collins bradley patient engagement network lead for the organization and i have nothing to disclose thank you kindred healthcare leading age good morning i am aaron tripp vice president of financing and reimbursement policy at leading age and i have nothing to disclose thank you national hospice and palliative care organization hi i’m jennifer kennedy i’m the senior director for quality and regulatory and i have nothing to disclose thank you national partnership for health care and hospice innovation hi this is svedmar grodeski policy director with nphi i have nothing to disclose thank you national pressure injury advisory panel yes hi my name is jill cox i’m a board member of the npiap and i have nothing to disclose as well thank you national transitions of care coalition snp alliance good morning this is dr stephanie chagini and i have nothing to disclose all right and just checking on mute issues do we have anyone from amda kindred healthcare all right so now uh what we’ll do is we will move on um to our disclosures for our subject matter experts so because subject matter experts sit as individuals we ask you to complete a much more detailed form regarding your professional activities when you disclose there’s no need to review your whole resume instead we are interested in your disclosure of activities that are related to the subject matter of the work group’s work we are especially interested in any disclosure of grants consulting or speaking arrangements but only if relevant to the work group’s work just a few reminders you do sit on this group as an individual you do not represent the interest of your employer or anyone who may have nominated you for this committee i also want to mention that we are not only interested in your disclosures of activities where you were paid you may in fact have participated as a volunteer on a committee where work is relevant to the measures reviewed by math we are looking for you to disclose these types of activities as well finally just because you disclose does not mean that you have a conflict of interest we do oral disclosures in the spirit of openness and transparency please tell us your name what organization you’re with and if you have anything to disclose and again if you don’t please just say you have no disclosure so we can keep moving along so let’s begin with our co-chairs jerry would you be willing to go first here i’m jerry lamb and i do consulting work and research related to care coordination which is somewhat related to the measures we’re going to be um reviewing today okay thank you jerry and kurt yes good morning again uh kurt mckells i’m the chief medical officer for compasses healthcare i also sit on the quality committee for the american academy of hospice and palliative medicine i have nothing to disclose thank you kurt all right moving along dan anderson hi everybody um my day job is at the rely group um i guess new to disclose is beginning in this january i start serving as a project manager on a cms contract that’s our role is actually um doing content review qa and things like that on the pac um qrp pages that include sniff ltac earth so wait yeah sniff ltech nerf so i just wanted to disclose that not our work is not measure development related but okay thank you dan terry black good morning i’m terry black i’m a clinical assistant professor of nursing at the university of massachusetts and i also am a per diem surveyor for a joint commission and i have nothing additional to disclose thank you sarah livestream let us say hi this is sarah levesey i am my day job is as uh the assistant dean for specialty education at rush university i’m an acute care nurse practitioner by training and i have nothing to disclose all right paula mulhausen paul are you with us this is amy i

believe paul’s in clinic this morning but he’ll join us later okay great thanks amy ricky mangram good morning this is ricky mangram i’m a principal researcher at american institutes for research and i would disclose that i’m also the chair of the quality measures committee for the for amda which is the society for post-acute and long-term care medicine thank you eugene nuccio uh the new ceo my apologies not a problem um i’m a retired professor at the university of colorado ancient medical campus in the division of healthcare policy and research on my specialty area is in home health i’ve sat on several nqf committees including the committee the panel that worked on um sociodemographic inclusion in risk models and um i’m a currently a member of the nqf uh scientific methods panel so i’ve reviewed many of these measures as part of that panel thank you all right now we’d like to move on to invite our federal government participants uh to these so these are the non-voting liaisons from these institutions for the work group so do we have the liaison to pack ltc here from the cdc good morning this is uh yeah senator andrew geller from the division of healthcare quality promotion at cdc thank you and uh the liaison from cms yes hi this is alan levitt i’m the medical officer in the division of chronic and post-acute care and i have nothing to disclose thank you um our liaison from onc hi there good morning i’m liz polina hall a nurse informaticist in our office of policy um at onc all right excuse me can i jump in can you hear me yes i’m sorry this is mary vandicam from kindred for some reason i was unable to um unmute and i gave my announcement about three times so i apologize um i’m the chief clinical officer for kindred healthcare in our um krs division i’m speech pathologist and i have nothing to disclose sorry i was unable to get in earlier thank you so much and again i hope you did this but if i have to say what else raise your hand and the staff can chat with you okay perfect all right thank you i panicked instead of thinking through it thank you no worries thank you for your persistence all right so now we’re gonna go back and do that whole drill again on the hospital side um so uh to begin with um do our hospital co-chairs want to provide any welcome as we start here um sure good morning everybody this is sean morrison i’m one of the hospital um coaches and just wanted to welcome everybody to today’s meeting and thank cms for all the work they’ve done in preparation as well as the nqf staff and i’m mckean demohan i’m the other hospital work group co-chair director of policy with the american hospital association i just want to extend my thank you to all of you especially those of you working in um hospitals and health care systems at an incredibly busy time for making a full day for you to participate in this important meeting and of course thank you to cms for your continued collaboration and preparation for this meeting and we’d be nowhere without the tremendous work of the nqf staff so looking forward to today’s discussion all right thank you so much so um again we’ll begin with organizational members remember you’re representing an organization there’s just one question we ask you to disclose if you have an interest of 10 000 or more so let’s go around our virtual table here um america’s essential hospitals hi everyone uh mary ellen gainen uh principal policy analyst at america’s essential hospitals and i have nothing to disclose thank you american case management association all right we’ll loop back remember raise your hand if you’re having trouble getting off a mute we’ll help you figure it out american society of anesthesiologists hi i’m vilma joseph i am vice chair of the committee on performance and outcomes measurement and i have nothing to disclose thank you american society of system pharmacists hi good morning my name is anne alegre duck i’m the senior director of clinical guidelines and quality improvement at the american psychologist of pharmacists and i have nothing great thank you association of american medical colleges good morning i’m dr janice orlowski i’m the chief health care officer at the association i’m also a practicing nephrologist

i have nothing to disclose thank you city of hope good morning my name is denise morris i’m the director of quality and value analytics with city of hope and i have nothing to disclose thank you dialysis patient citizens good morning jackson williams vice president of public policy i have nothing to disclose thank you greater new york hospital association hi this is amy chan i’m a senior director of health economics and outcomes research with the greater new york hospital association and i have nothing to disclose thank you henry ford health system hi this is santosh modiraj i’m the quality manager for performance improvement and data analytics and i have nothing to disclose thank you intermountain healthcare all right we’ll loop back around to intermountain uh medtronic hi it’s karen shahady and i work at medtronic and as a for-profit company i do have stock and will refrain from any topics that may um pose any kind of conflict of interest thank you memphis business group on health hi this is christy travis and i’m the ceo of the memphis business group on health working with self-insured employers across the state of tennessee and i have nothing to disclose thank you molina healthcare it’s debbie wheeler i’m the vp of quality for molina healthcare i have uh disclosure just in terms i have stock and molina but i don’t know if that’s a real conflict or not so i just say it out loud okay thank you for your transparency mothers against medical error i uh this is lisa mcgifford i am a patient safety activist with mothers against medical error and i have nothing to disclose i’m based in austin texas thank you national association for behavioral health care good morning i’m frank ganassi i’m a member of the board of directors at the national association for behavioral health care and also to share their quality committee and i have nothing to disclose thank you premier healthcare alliance good morning i’m aisha pittman the vice president of policy at premiere and i have nothing to disclose thank you press gaming hi i’m tejal gandhi chief safety and transformation officer at pressgany and um i do have equity in the company so i’ll disclose that but nothing else to disclose and um also i have to leave a little bit early so my colleague casey glavich is on with me so i’ll let her introduce herself as well thank you sean hi this is casey glovic i’m the director of policy at press gaming and i have nothing to disclose thank you project patient care good morning i’m marty hatley i’m the president and ceo of project patient care and i have nothing to disclose thank you service employees international union um hi i’m sarah nolan i am the director of health policy at sciu and i have nothing to disclose thank you society for maternal fetal medicine hi this is kelly gibson i’m a maternal fetal medicine specialist in cleveland ohio and sit on the patient safety and quality committee for smfm i have nothing to disclose thank you stratus health great good morning everyone i’m jennifer lembley president and ceo at stratus health and i have nothing to disclose thank you upmc health plan hi good morning everyone my name is gian donnis i’m the senior director for hospital and physician quality performance at the system level not just a health plan i’m replacing amy helwig who has served on this committee in the past thank you all right just a quick look back to the american case management association and to intermountain hi good morning it’s mike woodruff um interim chief patient experience and quality officer for intermountain um nothing to disclose i do have to step away for a bit and my colleague elizabeth mcknight will be substituting for me so i’ll introduce elizabeth elizabeth are you able to get off of mute hi yes i’m elizabeth mcknight i work in the office of patient experience with mike woodruff and i have nothing to disclose all right thank you so much okay so now we’ll continue we’ll move on to our uh individual subject matter experts a reminder just the same as last time use it as individuals there are more detailed uh disclosures here um and hope uh i won’t read the entire uh piece again um let’s start with our co-chairs so uh akeem sure so as i mentioned earlier i’m a director of policy for the american hospital association

primarily focused on quality measurement programs that affect our member hospitals and health systems i have nothing to disclose thank you and sean yeah hi everybody shawn morrison um i direct the national palliative care research center and am um the system chair for geriatrics and palliative medicine for the mount sinai health system in new york and i have nothing to disclose thank you andrea ballen cohen good morning i’m andrea bellan cohen healthcare economies by training i’m a vice president at impact my disclosure today is that impact has some projects developing measures for cms um this is my third year on the committee that’s it thank you lindsay wisham yes good morning i’m a senior director at intelligent over quality measurement and my contract or my employer does have cms contracts uh nothing that pertains to the measures we’ll be reviewing today and i’d also like to disclose i’m the patient representative on the macra measured development plan temp thank you all right and now to our federal government participants who are non-voting liaisons um could we have the liaison from ahrq please yes good morning and happy new year um i’m mia desoto from the agency for healthcare research and quality and i lead the quality indicators program thank you do we have the liaison from the cdc yes daniel i lead the unit at cdc responsible for the national healthcare safety network nhsn thank you and the liaison from cms shelf driver from cms i have nothing to disclose thank you all right well thank you all for bearing with me that concludes our our roll call and disclosures of interest i will turn it back over to matt great thank you michael um and lastly just want to recognize two additional individuals uh for our separate work group meetings um from the rural health work group we have two liaisons that will be with us um uh on the pack ltc side it’s brock slaybach brock are you on the line good morning yes i’m here great would you just mind introducing yourself sure oh i’m sorry um brox flavor senior vice president of the national rural health association and headquartered in linwood kansas and i have nothing to disclose today here representing the uh rural measures application partnership work group thank you so much brock and happy to have you today um and then for the hospital side um the rural health liaison will be jesse spencer jesse are you on and like to introduce yourself yeah hi good morning also representing the rural work group my name is jesse spencer i’m a rural physician in utah i actually work with intermountain healthcare and then the medical director of family medicine at this point great thank you jesse um both both individuals will be providing input based on the rural health meeting that we had last week it actually seems like forever ago that we had last week um they both were very very much involved with the proceedings that happened during that meeting on all the measures that we’ll be reviewing today um so if there’s any point in time want the rule perspective both individuals will be able to provide that so thank you both very much for your time but they will not have any voting privileges during these meetings next slide please can you go to 10 becky thank you okay i’d now like to introduce michelle schreiber dr michelle schreiber is the deputy director for quality and value at the centers for medicare and medicaid services and she’s here to provide some opening remarks as well as a meaningful measure update and all the great work that they’ve been doing over there so dr schreiber i’ll turn it over to you we have your slides lined up thank you very much let me do a sound check matt can you hear me okay coming through beautifully wonderful thank you and good morning to everybody as matt said i’m michelle schreiber i am the deputy director of the center for clinical standards and quality at cms and also the director for the quality measures and value-based incentives group there this is my third year of the map it’s hard to believe and it’s nice to see so many people that i’ve gotten to know over the past couple of years so thank you welcome to the map 2020 that of course is in 2021 um we’ve obviously had some challenges with scheduling and we’ve compressed this into a very short time we thank everybody especially the nqf quite honestly for their flexibility in being willing to uh make these changes um and are deeply

appreciative to everybody for their involvement this has been an extraordinary year i think that goes without saying at the map last year i don’t think any of us would have thought in our wildest imagination that we have would have had a year like we have had with a massive pandemic that is global that has taxed health care to i don’t want to say its limits because i don’t think healthcare knows its limits but it certainly has been extraordinarily taxing but has revealed the resiliency and the dedication of health care and to everybody who works in it in any way shape or form on behalf of cms really thank you to each and every one of you as you know the measures application partnership is a partnership but it’s a formalized process that’s mandated in statute 1890 and 1898 the social security act if you want to know paid through from cms whereby you as an independent group of expert individuals convened by the national quality forum make recommendations to us at cns about measures that you believe are appropriate or perhaps less appropriate to be used in the various cms value-based incentive programs these programs are used both for public reporting and they’re used for payment as well as you are all very familiar with this is an independent process and we really treasure your expert opinion and really have made many changes over the years based on the input from the map so thank you we have many people on the line today both from cms our contractors they are experts we are not here to sway your opinion we are here to answer questions and to provide clarifications for you and so we enjoy that opportunity and look forward to working with each of you today i’d like to thank a few others as well in addition to those who are on the phone from cms our federal partners i know we have dan pollock i heard but dan budnitz also who will be speaking on the covid vaccines and our other federal partners such as ahrq who are on the line thank you certainly to the nqf our personal um welcome to chris querum who took over what is it even a week ago two weeks ago chris is the interim ceo of the national quality forum and he has just stepped right in it’s very exciting to have you in that role and obviously to all of you uh sherry and others at nqf who have worked very hard in putting the map meetings together and in convening all of the based uh meetings that you do and of course to each and every one of you on the phone i’ve had the privilege of getting to know many of you in the last couple of years thank you all for your participation and last but not least certainly to everybody who has worked on the front lines to your organizations who represent them please go back and say a special thank you to all of those providers at the front lines who have been taking care of cobin patients um it has been extraordinary it has been heroic and thank you for everybody’s efforts what i wanted to do today is um just outline some of the goals of cms when it comes to quality measurement just to ensure that this committee has an understanding of where we’re going in the future and also to seek your input on these slides so we have been having listening sessions on the cms quality action plan in value stakeholder engagement and input and really i’m looking forward to this being more of a conversation than it is me talking um and so i’m going to pause at many of the slides and just seek feedback and um if there’s not an opportunity that there’s something that you have wanted to know just please drop me an email and qf certainly knows how to reach me or put something in the chat and we will make note of it but would look forward to hearing your input on the cms quality action plan so thank you and without a due can we have the next slide please this was a disclaimer to the uh presentations that we had done but this may contain references to statutes and regulations but this really doesn’t uh necessarily that this isn’t actually rule writing um this is a you know an open conversation about where cms may be going directionally next slide i think our vision is your vision and the vision of many who have frameworks around quality measures and that’s really to

use the most impactful quality measures to improve outcome health outcomes and to deliver value by empowering patients to make informed care choices while at the same time i hope you recognize there have been significant efforts to reduce burden to clinicians next slide please what i’m going to talk about are the four goals and there’s a fifth one embedded here i’ll be curious to see if you think we should call it out explicitly but the goals of the cms quality action plan let me just back up for a moment because many of you are familiar with the hhs quality roadmap and last year hhs actually convened a group of external stakeholders to talk kind of about the state of what we’ll call the quality measurement enterprise and there are opinions all over about the quality measurement enterprise from we shouldn’t have any measures because they haven’t done anything to we need to have lots more measures because you know i’m a specific provider and there isn’t a measure that is relevant to me it’s clear that there is a lack of alignment in the quality measurement space it’s clear that there is work yet to be done and hhs put forward a road map that had three essential recommendations one was around measurement itself to review measures to try and align measures and reduce measures that are less impactful or that aren’t working view is around data data structures and data interoperability to make data as widely available as possible and third is governance um should there be an independent governance body for the quality measurement enterprise of the country and so with that background they published their hhs roadmap i believe it was in may with that background cms has been working for years if not decades actually in quality measurement and has developed the quality value-based incentive programs that have led the way for public transparency and the uh the um link to pay to payment either penalty or payment for organizations so that performance is tied to payment we think these programs have been extremely valuable and actually have noted significant increases in quality as well as reductions in cost over the years the cms quality action program is really an outgrowth of the work that cms has been doing for a long time including the first phase of meaningful measures which started in 2016 went public in 2017 and we’re in the process of putting meaningful measures 2.0 together and in each of the map meetings we’ve actually talked about meaningful measures the goals then of the cms quality action plan are to use the most impactful measures and i see we have an error in that first line there we’ll have to fix the typing to improve and streamline quality measurement and that includes alignment the second is to leverage these measures to drive value and outcomes improvement the third is to make measures as efficient as possible and we believe that much of that is through the transition to digital measures and then using advanced analytic analytic systems so that we can even look at measures differently the fourth is to ensure that measures are patient-centered and that could be measures that are specific around patient-centered care such as shared decision-making or ensuring that there are goals of care that are being met and also patient-reported outcomes so that we are sure that we are always hearing the voice of the patient and the fifth one which we have actually woven through all of these is to try and shine a spotlight on disparities so that we can close those gaps and provide equitable care for all next slide most of you remember meaningful measures 1.0 which had six different domains of care and 17 specific dom specific focus areas we’ve actually used this at cms to look at all of our measures in all of our programs and retire some measures that didn’t quite fit within the framework of meaningful measures we’ve looked for duplicative measures we’ve looked for those that you know are more one-off measures and certainly those that are topped out and we have over across over a period of time through a pre-formalized process made advances in aligning measures and

in reducing the number of measures that we have the next slide thanks uh through the meaningful measures 1.0 framework which was part of the patients over paperwork at cms we really have made significant improvements with a 15 reduction in the overall measure number of measures that are used in the cms medicare fee for service program um we’ve gone down from 534 to 460 unique measures in the fee for service programs so i know there’s a lot of talk out there there are thousands of measures used there aren’t this is the actual number and we continue to reduce that so that we get to a more parsimonious list overall the measures portfolio is also shifting in that we have high percentages fewer measures that are process measures and more measures that are outcome measures although i will say as i’ve said almost all the time there are important process measures there are important structural measures as a matter of fact and so although we are shifting towards more outcome measures where we will not eliminate processed or um structural measures either this uh streamlining of measures has an estimated millions of dollars of savings and millions of burden hours that we have also saved as well next slide meaningful measures 2.0 which is currently what we are working on and have sought public comment on and introduced at last year’s cms quality conference has seven different domains we eliminated the specific focus areas and we’re hoping that through simplicity we can be highlighting the most important areas of um measurement so person-centered care and if you’ll notice the patient is at the top is the true north person-centered care is the true north and it’s also our foundation in the voice of the patient the other domains include patient safety and i have to tell you are you curious what you all have to say we debate it if that should just say safety or if that should say healthcare safety teshell knows that debate i i specifically had asked her to weigh in on it because we know that it’s not just patient safety but it’s worker safety workforce safety facility safety but we intentionally left it as patient safety because that’s what’s fundamentally important chronic conditions seamless communication including interoperability affordability and efficiency wellness and prevention in behavioral health and substance use disorders is one that we added because we recognize just how important this is transitions of care we put in both seamless communication and chronic conditions although we’ve heard some feedback that maybe we need to call that out a little bit more explicitly and the goals i’ll talk about in the next few slides but utilizing measures of high value aligning them prioritizing them transforming them to digital um ensuring that we’re hearing the voice of the patient and we’ll talk later about social and economic good determinants let me pause for just a moment and ask the group on this house diagram would you like to see anything differently did we not capture some key domain or would you reword it differently so maybe we can just spend a couple of moments and you can either chat or raise your hand matt if you wouldn’t mind facilitating and see if there are any comments from the group on the box the house thanks michelle so you can chat send a chat or you can chime in take yourself off mute if you’d like to provide any input well this is marty halley i’d like to to comment on michelle’s comment about patient safety i i think that that term now strikes me in 2021 as sort of an interim term that’s changing um cms i think um helped inform the dialogue several years ago by shifting from patient to person in a lot of your planning documents and that resonates with me because i think workers are persons too the persons in the system i think uh all have safety interests and um so when i look at the word patient safety now even though i’ve spent my career sort of wrapped around that term it feels too narrow uh prospectively because it really is about person safety and it’s not just patients it’s residents of long-term care facilities it’s it’s words for which patient is not it’s not precisely the right word even though it’s the word that’s out there so um i i think person safety could be

something that we should consider going forward i see a number of comments by the way i’m sorry lisa i just see a number of comments i’m trying to read the chat while i’m uh looking at people and having the conversation around health care equity i will say there was a lot of debate about health care equity should it have been should it be sort of one of those foundations like we have voice of the patient we put health care equity as a foundation should it be within the box i’m curious what people say we wove it into each of these but if you think that we should call it out more explicitly i’d like to hear that feedback as well and i’m sorry at least i didn’t mean to interrupt you oh oh that’s okay it’s kind of hard to know how to raise your hand um yeah somebody has one i tried to find that symbol and i couldn’t oh there it is uh i would just take the uh the position that i think patient safety is an important phrase uh i think uh healthcare provider safety worker safety is important too um certainly long-term care resident safety is important but i see those as um coming under a different category or a subcategory perhaps for long-term care but um if we want to add something for worker safety which i think is totally valid i think it should be a separate category i think the strategies are different and you know what the activities you have to do are really different for that um for that group and uh jerry jerry did you have your your hand raised i did i wanted to comment on the seamless communication michelle and would encourage cms to consider using care coordination as the broader umbrella for seamless communication and transitions of care i think our work in in the cdp suggests that they’re not the same and care coordination gives us a much fuller process thanks i think matt will take one more comment and then i’ll move forward that sounds good thank you uh michelle and i have deja hi there um i’m michelle i thought i would just comment about the patient safety topic as well i mean um i think i told you that we had our national steering committee for patient safety that really debated this issue of due date safety and patient safety and workforce safety and what do you say and there was concern that if we didn’t say patient safety it would first of all confuse people because we’ve been talking patient safety for 20 years and um and it is to marty’s point i think a term that it will be transitioning to that broader safety but we weren’t sure if we were quite there yet to do it now that being said i also agree that workforce safety really more and more is you know we know is critical that’s in the we say that work worker safety is a precondition to patient safety and actually to doing any of the things that we’re talking about on this slide we need to have you know a safe workforce so i almost see that as like a foundational element underneath all of this in order to achieve person-centered care patient safety all that stuff we need that workforce that’s supported um maybe highlighted separately but still mentioned great well thank you all i recognize we don’t have a huge amount of time and i i will try very hard to run on time matt how about if we advance to the next slide please that sounds good and michelle i’ll just note too that we we will be able to save and capture everyone’s input in the chat so if you’re not able to participate uh on the call please provide it in the chat and we can definitely share accordingly great thanks let me go through again and highlight the goals of the cms action plan and then i’ll pause after i do some of these goals so that we can open the conversation again the first is using meaningful measures to streamline quality measurement and a lot of this has to do with alignment alignment alignment reducing the number you’ve heard about our efforts to date of decreasing the number of measures i think we are in the process of doing that we’ve made significant headway and we will continue although i have to tell you we don’t have some golden magic number of the number of measures there should be either at all or in the cms programs i know you know again there are opposite ends of the spectrum from no measures or two measures to more measures we think it’s the right number of measures that are covering the right uh key domains there’s been a lot of

alignment work that is going on within cms there’s an alignment committee between all of the centers of cms so these are the medicare fee for service programs for the most that you see but there are programs for medicare c and d there’s obviously the cmmi innovation models there’s medicaid that has to be taken into consideration and so we’re working hard within cms to bring alignment we’re also working with our va and dod federal partners to bring alignment more across the federal work space as a matter of fact i was on the phone this morning with the va and dod we have frequent meetings to try and do that as well and many of you actually are participating in and know the work of the poor quality measures collaborative which is sponsored by nqf cms and ahip america’s health insurance plans thank you to them which has just developed i measure sets these are all ambulatory at the moment there’s eight in development there’s two more being worked on that are actually sets of key measures that we have agreed to use across all payers so the more we can get to an all payer point of view i think the better so lots of efforts going on in this direction next slide meant please obviously we want to take those measures in the measurement enterprise and use them within whatever programs some of them are public reporting some of them are just confidential feedback some of them are pay for performance but use them in our programs and we’re trying to modernize the programs across cms and i think you’ve seen the evidence of that you’ve seen the transition from mips to mixed value-based pathways which are smaller sets of related measures that darva being developed in close collaboration with the specialty societies we’ve modernized the hospital stars program and you probably saw in the recent legislation that passed the consolidated approp appropriations act and i know the uh back and long-term care folks will talk more about that an expanded sniff value-based purchasing program so that it’s not just one measure for post-acute care and sniffs we have the mandate to include or the opportunity to include up to 10 so that we’ll have a more holistic program for skip for nursing home value-based programs we also had been looking at many of you have heard this before a hospital simplification model where we took all of the five programs of the hospitals and tried to unify them into a single more simplified program so that remains a subject of conversation across cms so we are trying to use these measures appropriately and modernize the value-based programs as possible it’s like i want to talk a little bit about the digital transition many of you have heard me speak of this before but cms at last year’s quality conference the administrator herself announced that cms is going to transition to all digital quality measures you’ll see in the muppets this year that 80 percent of our measures are indeed digital and we’re making a significant and concerted attempt to move all measures to digital by 2025 actually accelerating that timeline now i know that that’s perhaps inspirational aspirational but we’re making strides in that direction and you can see it from this year’s map i say that because in the future um cms probably won’t accept as new measures into their programs measures that aren’t digital so those who are thinking of bringing new measures forward onto the muck and math list i will tell you that that is our point of view at this point at this uh time and please consider that actually in your deliberations or even as you’re thinking in your mind of what measures should be brought forward now i have a very broad view of what a digital measure is obviously there are electronic clinical quality measures that come directly from electronic medical records but there are also other digital means such as what do we do with information that may come from patient downloadable devices such as what do we do with census information such as what do we do with claims information most of which is captured digitally and so it’s a broad view of digital but i think all of us need to become very conversant in digital measures and ecqms because that we think is a way of moving forward that will help ease the burden of measurement perhaps not in the short

run as these things have to be built but in the long run so that this is all digital and we can have a seamless communication of information having digital measures also allows us to leverage whatever you want to call it advanced advanced learning neural networks machine learning artificial intelligence but advanced analytics so that we can be looking at measures in a very different way digital measures also allows cms to provide much more relevant feedback in point of fact eventually in a real time manner because we know that right now quality has been somewhat retrospective and we need to push that so that it is much more timely so that we can really be part of creating those learning health care systems that i think we all aspire to and on the next slide empowering patients to make the best health care choices through patient-directed quality measures we spoke of this before for public transparency cms this year introduced its updated compare sites making them easier for patients and consumers to understand we’ve made a commitment to increase our patient reported outcome measures by 50 percent to be quite honest with you when you don’t have that many of them 50 percent isn’t quite as much as it sounds but our goal is to increase reporting by patients and to include patients in everything that we do so we now include patients or have been for a while on all of our taps but even as these mixed value pathways are being developed we’ve asked all the specialty societies who are working on this with us to ensure that they include patients and that we’re looking at a patient-centered measure in all of them and it may be a patient-reported outcome measure or it could be something related goals of care shared decision making but to make sure that we are doing patient reported outcomes and on the next slide i want to talk a little bit about disparities in equity because even though it wasn’t in the house slide this is something that siena’s takes very seriously and we’ve tried to weave it through all of the goals that we’ve had although more and more i think we are going to call it out specifically in the in the slide with the house diagram so thank you for your feedback on that we are have already been providing confidential feedback largely to hospitals with some measures based on dual eligibility we will provide be providing more and more of that over time not only to hospitals but in other programs and envision at some point making those public as well but that will take a while until i think all of us are used to seeing it and we’re more sure of our data we’ve been looking obviously with nqf over the past year several years about what are some appropriate measures do we have appropriate measures for ses then we probably don’t have enough and we’re also partnering with our office of minority health looking at the head score which is a health equity score which actually assigns a score based on some of the local characteristics of in geographic characteristics of the area as well as characteristics of the practices so we are looking very much at health equity and i have a couple of other slides specific to health equity in a moment but that’s a separate topic that i want to get to let me pause here and ask matt if we can open up the conversation again on these four goals and these directions of cms regarding quality measures would love to hear everybody’s input thank you and i’ll assume if there’s no comments you just all agree with us thank you so much so uh michelle i’m just looking at the uh ray’s hand akeem do you have your hand raised would you like to provide comments or questions i i do indeed have my hand raised good morning michelle it’s great to see you hi again thanks so much for the uh the overview of cms’s activities i i wanted to dive just a little bit deeper on the uh the notion of digital measures um you know i think when i when we’ve thought about digital measures we often think of them mostly as ecqms this construct seems a little bit broader are you drawing any distinctions between ecqms and digital measures um a little bit of definition might help yeah to be honest with you we’re trying um to be as broad as we can at least to start with a keen because we want to make sure that we can embrace

everything that may fall under a digital um kind of definition we will actually be introducing into some formal rule writing our definition of digital measures and to be honest with you we’re still refining that i know ncqa also has a definition of digital measures i think there are a few definitions of digital measures that are floating around out there but ecqms is actually a subset a large subset of digital measures and i think over time we’ll probably get to a point where most of this is ecqms but i don’t know that we’re there yet nor do i know that we will ever completely be there because there are these other digital data sources that i think we’re going to want to include as well i i think it’s actually good that you’re you’re trying to think broadly about what digital measurement looks like um you know it’s always a balance between being broad enough to be inclusive but specific enough so people really know what you mean but uh look forward to continuing the conversation about that i’m glad you’re thinking about it yeah thanks the other thing is that we’re obviously partnering with onc too on what digital quality measures look like and what the capabilities are so cms has really been at the leading edge of translating quality measures into fire fire api measures we have standardized data elements for ecqms actually on the cms website we’ve worked on standardized elements we’re building actually the fire servers within cms that can take bulk data around this stuff we’ve been at the leading edge of that you can imagine that some years going forward start certification may include may include the necessity of delivering quality measures or collecting quality measures in a way that are interoperable and so there’s a lot of work that translates this interoperability as well great uh and also oh sorry uh michelle i also have janice orlowski janice do you have a question or comment i do thank you good morning hi michelle how are you hi janice um you know i uh first of all applaud the work that you’re doing and i think that uh many of these are the key areas one of the things that i’d like i was wondering if you would delve in a little bit more give us sort of your thoughts is the diversity and equity uh gaps you’re talking about you know that we’ve been um for years looking at how we can take a look at social demographics differences how they can be measured in order to improve them and we have recently spent a lot of time looking at equity um gaps in quality and safety and so i was just wondering what uh what direction it i think and let me just say this i think unless we come up with the standard uniform sds agreed upon metric that we’re all going to be measuring that we’re going to be floundering and so i i was wondering if you could make any comments or give us thoughts about what direction cms is headed thanks yeah thanks janice for your question and i think you’re right we don’t have clear ses measures for one for example is it food insecurity is it transportation is it income is it race what is it i don’t think we know and there’s certainly a lot of research that has yet to be done about that the things that we’re looking at is one to start with this confidential feedback so that organizations and providers can at least look at their data based on duals which is what we have and i have a few slides about something different that i want to um to share with the group in a few minutes but based on duals so that because i think step one is ensuring that hospitals in particular because they’re very used to looking at their data but all facilities all providers are actually looking at their information ratified appropriately and by appropriately i think that’s up to the organization but at least by duals and as well as other real race ethnicity and language information that they may have i think there’s a challenge at cms and across the federal government in that we don’t have as much information as people may assume that we have um and you know part of that goes back to a number of years ago when social security stopped collecting that data on enrollment and so we need a standardized way of even collecting the data to make sure that we have it now i know a lot of organizations have it

you know a lot of organizations put in a lot of work i know when i worked at henry ford and hi to my henry ford colleagues i we put in a tremendous amount of effort in collecting real data but i will tell you that cms doesn’t necessarily have that so for us to provide that reporting is actually a little bit more difficult so i think a it’s giving people information b it’s making sure that organizations are looking at their data and then acting appropriately and then see again we’re working with the office of minority health about what might be something like the hess score the health equity score is that one that we can rally around or frankly are there others i think they’re a broader conversations that we need about this well in in i appreciate that in my you know final two comments a number of the larger vendor ehrs are starting to put in some kind of an sds uh you know program and yeah that you know that’s good but um you know we can’t have six of them out there so you know if there was some standardization that’d be good and the other thing you know since i’m you know that i still practice um uh part-time it you know physicians really have never been educated on z codes um you know i’m aware of them um because i’m the chief health care officer at the wmc not because i’m a practicing doctor and i think that if we took a look and said you know what are the critical z codes so you know if if there were two z codes or three z codes rather than the multitude that we have but but if you said let’s take a look at the use of z codes over you know a six month or 12 month period of time educate physicians i you know i could add a z code um to to my care what i can’t do is i can’t um add 20 of them because i just don’t understand um their importance and you know whether we’re doing them right so those are um two those are sort of two comments that i don’t want to get so far ahead that we have all of these on the standard platforms out there it’s a good point and you’re absolutely right matt what do you think one more comment and then i’ll move to the next slides sounds good uh do we have any other hands raised we do we have tejal go ahead tajal thank you um michelle i know you and i have talked about this but you know you mentioned the distinction of um process measures versus outcome measures and in this particular area i think that’s an important thing to think about because you know we’ve been doing an initiative with over 200 health systems to segment uh patient experience and workforce engagement data by race and ethnicity as a starting point and doing work with them to understand the quality of their race and ethnicity data giving them strategies around improving the quality of that data and so i think um you know when you think about process measure most organizations or many organizations you know will segment maybe a couple of clinical outcomes like diabetes or hypertension and then there’s sort of you know check the box yes we’ve done something here so i think sort of moving into process around data quality making sure they have ways to and you can measure that relatively in a relatively straightforward way so starting to push organizations to improve the quality of their data and pushing them to segment more than just those one or two clinical measures but really across the board on many of their measures like i mentioned experience and engagement but there’s many others as well that may be a way um to try to accelerate progress here with the process measure side yeah so thank you and i’ve seen a number of uh ones coming through the chat so we’ll look at we will take all of those into consideration so thank you since we’re speaking of equity let’s go into uh the next slides if we may not um and i wanted to run something by the group and see what you all think of this so i’ve shared that we really don’t have great data on race ethnicity and none on language next slide please and you can actually see the data so that when we look and the national academy of med of medicine and aspie actually have recommended stratifying data when we look at providing confidential feedback we have limitations in the accuracy of the demographics so that you can see the sensitivity sensitivity and specificity is not bad when it comes to is a patient white or black it’s not perfect but when it comes to ethnicity you can see for the latino hispanic population it’s terrible um asian pacific not great and american indian population is uh even worse so we have lots of room to go when it comes to

making sure we have data that is correct next slide there are models out there many of you i’m sure are familiar with the mirantes1 rti has another one where there’s an indirect estimation in other words you impute race ethnicity you can’t do language and you can see that the numbers get much better when you use one of these models we also recognize the sensitivity the political sensitivity of telling people we’re going to impute your race or your ethnicity and really would like to bring forward the concept of using some of these models in providing confidential feedbacks that cms would like to well be able to share with organizations so getting to your uh some of your comments of being able to use more than dual eligibility in confidential feedback but out actually providing further information how would this group feel about using some of these imputational models you’ve seen that the data does get better nqf and iom have actually supported this but we also recognize that we think it’s a little bit sensitive to say that we’re using imputational models for this as opposed to direct data collection the next slide so i think i’ve covered most of this already but we haven’t used this previously in risk adjusted quality outcome measures and are considering or at least having conversations about doing this through confidential feedback and would really like the opinion of the group so matt i will pause it there and we can open it up again we currently do not have any raised hands vilma just raised her hand go ahead you’re muted velma yes thanks okay yeah so i really think we should take more time and ask for direct information uh as opposed to using indirect estimates uh it may be more labor intensive it may seem more invasive but i think if we allow people to get into the habit of providing the data they will do it like they supply you know the date of birth or the social security number uh so i i think if we uh just make it seem that it’s expected that our patients will provide the data in an accurate way thank you so we have to say all right we’re coming to a close for this section any other last comments that people would like to add something different to the cms action plan something you’d like to see us do differently accelerate not accelerate akin has his hand raised i do so uh just reflecting a little bit on the uh the notion of indirect estimation michelle um you know i i think i get why uh the indirect estimation approach has some appeal um because it does take the data that you have and try to leverage it uh and create a more comprehensive picture i do think that there is yeah there i think that there are some challenges with making some statistical guesses about the race and ethnicity of patients and there’s something about it that doesn’t sit entirely right i do know that hospitals have been working through um approaches or collecting the race and ethnicity data in a more consistent fashion and i think one of the one of the challenges that we continue to face is figuring out at what point um during care delivery it makes the most sense how do you leverage um patient encounters in the most effective way um and i would say this applies not just to race and ethnicity i think it applies to a broad range of social determinant of health related data i i don’t have a simple and elegant solution for you

at this point i do think it’s a conversation that we we need to have as a field i think we also have to try to think of ways of getting creative about where we obtain the data this is going to sound a little off the wall so take it with a grain of salt but you know i do wonder to what extent when we enroll patients in medicare and medicare advantage to what extent any of that data can work its way into medicare claims so that we’re at least getting it at one point in time that may work for some kinds of data but not for others but really thinking about how we can all work together to make sure that um providers are collecting what they should um but not more than they should uh and that if there are existing sources of data out there that we’re using them to to the best effect that we can i am really glad that you’re looking at this issue because it is a very very important one so thank you and i know that we’re coming to time we will obviously as a larger community i’ll be thinking through this but these are huge issues that we do have to be addressing let me be very clear when i talk about the indirect estimation that if we were to do anything it would only be confidential feedback reports to whomever not public because we recognize we are far from that so i don’t want people to think that we’re talking about using this in public reporting um it’s really it and it may even just be some pilot projects to say what does it look like and does it make sense but i agree with you akeem there are there are things about it i mean the data obviously looks like it’s better but there are things about it that i don’t know don’t necessarily feel right so i think we need a lot more work around it but these are models that are out there and then are actually being fairly well used but we will definitely consider this conversation and continue the conversation i wanted people to know that we are thinking seriously about it and thinking seriously about how to look at issues of disparities because first of all all of us knew this all along but second of all the covid pandemic has certainly highlighted the absolute need for us to be addressing this issue and we look forward to having the continued conversations well with that i want to thank all of you for participating in this conversation this morning again if you have comments anything on the cms action plan that you would like to see different or even just engage in a conversation around it please don’t hesitate to reach out to me personally or to any of the staff at cms i’m sure many of you work with us at cms in different ways and uh let me turn this back to nqf to continue the rest of the day and uh thank nqf for moderating and for also giving me the opportunity to speak this morning so um thank you and look forward to the rest of the day thank you very much michelle um again i do want to iterate that if you have a comment or question please put it in the chat box we definitely will capture that as we as we move forward accordingly for the next uh portion of the agenda we’re really going to be talking about the overview free rulemaking approach and i’ve got two of my colleagues will be presenting this about janaki panchal who’s the manager of quality measurement she’s working on the pac ltc work group and also udara pereira she is our senior manager here at quality measurement and she’s working with us on the map hospital work group so jonicki you’re starting out i’ll turn it over to you wait thank you so much matt hello everyone my name is janaki panchal and i’m a manager on pac ltc map pack ltc work group here at nqf um so we’ll now take a look at the preliminary analyses of measures under consideration and walk through the preliminary analysis algorithm um next slide please thank you um so before we go into the algorithm i want to highlight a few things about the about preliminary analysis or the pa basically nqf staff conducts a preliminary analysis of each measure under consideration um and the goal of the preliminary analysis is for the nqf staff to flush out each measure under consideration in some detail and to create a succinct profile of each measure by really giving a brief rundown of the measure and a preliminary look at how it

compares to the evaluation criteria and the intention really is to facilitate help facilitate the map work group discussions and serve as a starting point for these discussions in order for us to conduct the preliminary analysis the inquiry of staff uses an algorithm which we’ll look at on the next few slides and this algorithm was developed from the math measure selection criteria to evaluate each measure in light of maps previous guidance this algorithm was approved by the map coordinating committee and it is an important aspect of the overall process next slide please looking at the algorithm now i know uh there’s a lot going on on this slide but we have seven key components or criteria of the preliminary analysis algorithm each criterion is listed here in the first column in the next three slides and the definition of each component is in the middle column which uh just provides further clarity on what each of these assessment components are looking at and then the outcome of each component is in the last column here on this slide i won’t read through everything but we will briefly go over each one here so the first assessment criterion is the measure is if the measure addresses the critical quality objective and not adequately addressed by the measures in the program set and what this really means is listed in the middle column there for your reference and for the outcome if we say yes the measure does meet this criterion then the review continues however if we say no then the measure will receive a do not support for recommendation as the decision category category designation and we will look at what each of these decision categories mean in more detail in the next section and also map may provide a rationale for the decision to not support or make suggestions on how to improve the measure for a potential future support categorization the second criterion here is if uh the measure is evidence-based and is strongly linked to outcomes or is itself an outcome measure so for this component if the measure is a process or structural measure we are really looking to see if the measure has a strong scientific evidence base to demonstrate that when the measure is implemented it can lead to the desired outcomes and for an outcome measure we’re looking to see if the measure has a scientific evidence base and has a rationale for how the outcome is influenced by healthcare processes or structures similar to the outcome of the previous criterion if we say yes then the review continues if we say no then the measure will receive a do not support recommendation and again map may provide a rationale for the decision to not support or make suggestions on how to improve the measure for a potential future support categorization now the next assessment criterion is if the measures addresses a quality challenge so if we say yes then similar to the previous two criteria the review does continue and if not then we do not support the measure for implementation but again math may provide a rationale for that decision to not support or make suggestions on how to improve the measure next slide please so for the next couple criteria now the algorithm does change a little bit in the sense that we need to pass those first three assessment criterias first so the fourth criterion is that the measure contributes to efficient use of measurement resources and or support the alignment of measurement across programs if the answer is yes then the review continues however if the answer is no then the highest rating can be do not support with potential for mitigation um so if the committee does arrive at this decision category then the committee would outline precisely what the measured developer should do to improve the overall uh to improve the measure overall for future support the next criterion is if the measure can be feasibly reported the outcome is similar to the previous criterion if it’s yes then the committee continues to review uh the measure and if no the highest rating is do not support with potential for mitigation

um and again provide how to potentially mitigate the measure along with any sorts of rationale for how we arrive at that decision next slide please so the next criterion here is that the measure is applicable to and appropriately specified for the program’s intended care settings levels of analysis and populations this generally means that the measure is endorsed and if it’s not increasing doors the measure is fully developed and specifications are provided and the measure testing demonstrates reliability and validity for the level of analysis program or settings for which it’s being considered so if the outcome is yes then the measure can be supported or conditionally supported if the outcome is no then this highest rating can be conditional support and math in this instance dictates what those conditions are and suggests how the measure can be improved and the last criterion is if the measure is in current use and there haven’t been any negative unintended consequences to patients and that burdens don’t outweigh the benefits the outcome of this is that if there’s no negative unintended consequences or implementation issues and the measure can be supported or conditionally supported however if there are implementation issues then the highest rating should be conditional support and math can elect to provide a rationale at this point and how they think if those challenges could be overcome or anything else that the measure developer should consider uh before we move on to the next section i’ll pause to see if there are any questions on the algorithm okay uh hearing none do we have any questions in the chat or if there are any hand raised all right so we’ll move on to the next section now uh next slide please wait um so we’ll briefly take a look at map voting decision categories now next slide please each measure is assigned a dis decision category and map work groups must reach a decision about every measure consideration um again i know there is a lot of information on this slide as well but we’ll review what each category means and try to link it back to the evaluation criteria that we just looked at um so as you can see on this slide there are four decision categories that are listed in the first column on this slide in dark green the first is support for rule making the second is conditional support for rule making third is do not support for rulemaking with potential for mitigation and the last one is do not support for rulemaking so the first category support for rulemaking means that map supports implementation and map has not identified any conditions that need to be met prior to implementation and then linking this back to our evaluation criteria what this means is that measure is fully developed and tested for the setting in which it’s going to be applied and that means that the measure meets the first six evaluation criteria that we saw on the previous slides um and if the measure is in current use um then it should also meet the last evaluation criteria which was about unin unintended consequences and burden the second decision category is conditional support for rulemaking this means that overall map supports implementation of the measure as specified however map has identified certain conditions or other modifications that would ideally be addressed prior to implementation in terms of our evaluation criteria what we are saying is that the measure meets the first three evaluation criteria the designation of this category assumes that one of the criterion between assessments four through seven has not been met and ideally those modifications would be made before the measure is proposed for use the next decision category is do not support for rulemaking with potential for mitigation and for this category map does not support implementation of the measure as it specified but map agrees with the importance of the measure and has suggested material

changes to the measure of specifications for this category the measure meets the first three valuation criteria but the measure can’t be supported as currently specified and a designation of this category assumes that at least one of the criterion from assessments four through seven was not met and the last decision category is do not support for rulemaking and that simply means that map does not support the measure and this is when the measure under consideration doesn’t need at least one or more of the first three measure evaluation categories so those are the four map decision categories i will pause once again to see if there are any questions before we move on i’m hearing none so i’ll turn it to udara who will walk us through the map voting process thank you so much janaki next we’ll talk about the voting process that we conduct on map next slide please one of our key principles is that of quorum and this is ubiquitous across the national quality forum we require a certain percentage of the work group to be present for map quorum is defined as 66 of the voting members that have to be present virtually for the meeting to commence so since we’re convening completely virtually this year we need to have 66 percent of the committee present in order for us to be able to take any vote so once we establish that quorum is present that process involves simply taking a roll call or an attendance so at any given time we can determine if quorum is established at the beginning of the meeting but if we feel that we’ve lost quorum we can do a check before we actually conduct a vote so if we don’t establish quorum we’ll then vote via an electronic ballot after the meeting so we’ll present a recording of the proceedings and then ask map members to vote once we’ve conducted our business without the vote during the meeting but i am happy to announce that we do currently meet quorum for this meeting map has also established a consensus threshold and that is greater than or equal to 60 percent of voting participants who must vote positively and that a minimum of 60 percent of the quorum figure has to vote positively so one thing that i do want to point out is if for any reason you are conflicted on a measure we invite you to please recuse yourself and any abstentions do not count within our denominator and as i mentioned before every measure under consideration receive the decision category next slide please so here’s the stepwise process by which we conduct voting we have five steps within our voting procedure first our nqf staff will review the preliminary analysis for each measure under consideration using the map selection criteria and programmatic objectives next the co-chair will ask any clarifying questions or concerns from the work group and measure developers will then respond to these clarifying questions or concerns that are related to specifications on the measure and our nqf staff will respond to clarifying questions and concerns on the preliminary analysis for step three we vote on acceptance of the preliminary analysis decision category within the work groups so after clarifications have been resolved the co-chair will then open up the vote on accepting the preliminary analysis assessment the vote will be framed as a simple yes or no vote to accept the result if greater than or equal to 60 percent of the work group members vote to accept the preliminary analysis assessment then the preliminary analysis assessment will be the work group recommendation but if less than 60 percent of the work group votes to accept the preliminary analysis assessment then we open up the discussion for full review of the measure next slide please step four that’s the discussion and voting on the measure under consideration first the lead discussant will review and present their findings and map rural health liaisons will add in a summary of their work groups discussion then the co-chairs will open the discussion among the work group and work group members should participate in the discussion to make their opinions known however we just asked that we refrain from repeating any points that have already been presented there’s nothing wrong with agreeing with them and saying that it makes sense but just in the interest of time we want to keep the discussion moving forward and after the discussion is concluded the co-chairs will open up

a vote on the measure that’s under consideration so co-chairs will summarize the major themes from the discussion and chairs will determine which decision category will be put to a vote first based on where they think that consensus which was emerging from the discussion now if the co-chairs don’t feel that there was a clear consensus uh position then they’ll start at the top so the work group will take a vote on each potential decision category that that we just went over one by one the first vote will be on support and conditional support then do not support with potential mitigation and then finally do not support next slide please and our last step is tallying the votes so if a decision category put forward by the co-chairs receives greater than or equal to 60 percent of the votes the motion will pass and the measure receives that decision category but if no decision category greater than or equal to greater than 60 to overturn the preliminary preliminary analysis then that pa decision will stand this will be marked by staff and noted for the coordinating committee’s consideration in the case of the preliminary analysis standing and those are our five steps for our voting procedure i do want to pause here and see if there are any questions on our voting procedure dave anderson have a question go ahead yeah can you um can you say a little bit about um i know you talk about the discussions providing their preliminary analysis but is there some guidance on what you know what aspects that includes is it a full kind of discussion of their impressions of the measure from everything to reliability to exclusions things like that or is it just a bigger picture than that i can i can take that if you’d like um so dan this is matt uh thank you for the question uh and this great question so um we are looking for uh map input related to um how relevant this measure and how important this measure is for the program it’s intended for use um now with that in hand in hand there’s reliability validity types of testing to consider but those types of um statistical types of assessments or even reviewing the actual testing itself is really reserved for nqf’s consensus development process which is our standing committees that review these measures they’re looking at those actual qualities of the measure against our evaluation criteria for endorsement with this work group we’re really looking for based on what’s been submitted to you all in our preliminary analysis your review of that and assessment and also with the public comments that have been received and included in those preliminary analyses um what are your uh what what are your opinions or viewpoints or your stakeholder perspectives based on how appropriate this measure is for the program it’s being submitted for um and so there’s an assessment of the evidence there’s an assessment of how what’s the impact the quality challenge um all of all of that to be considered so if you’re having concerns related to testing for example if you’ve really looked at this measure and related to there’s some testing around reliability validity um there may be some um different types of voting that you could have such as conditional voting pending nqf support or n2f endorsement excuse me uh for example and so that would be where the nqf that measure would go through the ncap process and get evaluated on reliability and validity with our standing committees so it’s not so much in the weeds if you will with reliability validity testing so much it’s more how aligned is this measure to the program it’s being uh placed in all right it’s great thank you are there any other questions hearing none we will move forward to the next slide please we’re now going to give a brief overview of the role of the map rural health work group on the pre-rule making process next slide please the map rural health work groups charge is to provide a rural perspective on the measures that are under consideration to the other map work groups and committees and to help address priority rural health issues such as the challenge of low case volumes and as you heard earlier today the royal liaison for the pac ltc work group is brock slayback from the national rural health association and the role liaison for the hospital work group is jesse spencer from intermountain healthcare next slide please the rural health work group reviews the measures under consideration and provides input to all three of the setting-specific work groups with the release of the muck list we sent out the preliminary analyses

for the measures for your review the analyses were developed by our nqf staff and they’re intended to provide a succinct profile of each measure and to serve as a starting point for the discussions the rural health work group also received these preliminary analyses and they were able to provide us with input on the relative priority or utility of the measure under consideration in terms of access cost or quality issues that are encountered by rural residents they also provided input on data collection and or reporting challenges for rural providers in addition to any methodological problems of calculating performance measures for these smaller rural facilities they also provided input on any potential unintended consequences of inclusion within these specific programs as well as gap areas in measurement that are relevant to both rural residents and rural providers for these specific programs next slide please the rural health work group feedback for the setting setting-specific meetings we provided to the relevant work groups for their consideration today during the discussion and voting on the measures under consideration a qualitative summary of the discussion that the rural health work group had for each measure as well as the quantitative result of the rural health work group voting results are included in the measure preliminary analyses and we also have a rural health liaison for each of these setting specific meetings in order to try and summarize the discussions as well i’d now like to pause for any questions on the rural health work group in hearing none i’d now like to turn it over to did we have a question on the phone that’s me udara sherry that’s my phone number perfect timing sherry i’d now like to turn it over to sherry windsor of nqf to provide some comments on the kovid 19 measures thank you adara you did a really great job on presenting an overview of our process and helping everyone to answer their questions or or follow through on that so thank you um we uh as an organization um the national quality forum wanted to just we just want to be sure that we um provide a little bit of perspective or our perspective on the coven 19 vaccine measures and so my remarks will be brief and then we’ll turn it over to um to the cdc and um cms as well to provide some per presentation as well um many of you may note and we’ll see in our preliminary analysis of these uh measures that the preliminary analysis recommendation is they do not support with potential for mitigation and i just wanted to clarify um nqs perspective from two different issues when it comes to vaccines and then this measure we wanted to make sure that we really did maintain the integrity of the map selection criteria analysis and the algorithm that udara just went over and so um we know that the specifications that currently are available for the code vaccine measure aren’t quite as complete as i know the our colleagues at hhs have wanted them to be quite quite yet but they will explain quite a bit of that we want to make it very clear though that the national quality forum fully supports as an organization vaccinations and particularly in this case for the prevention of illnesses such as covet 19 but that our selection criteria and algorithm at the moment resulted in that particular that particular recommendation the support of vaccines though um is very different issues than what we’re asking this group to do today which is to provide feedback on whether this measure is the best way to measure the administration of the code vaccines and whether it’s healthcare personnel or patients so evaluating the measure and the specifications or or the preliminary analysis is different than our support of vaccine administration so um just wanted to make sure that we clarified that and that just because it says do not support it does not in any way mean the national quality form does not support vaccines and reminder that with potential for mitigation means that we also know that those specifications can be improved upon and provided more detail so i don’t know michelle if you wanted to speak to this or if i’ll just turn this over to to um dan i believe yeah thank you

sherry i’ll kick it off please we can go to the next slide thank you sure so we first of all absolutely recognize that nqf supports covered vaccination but what we are bringing forward to you are proposed measures that quite honestly aren’t fully fleshed out at the moment because we don’t have the data because this is all very new but we felt that it was important to bring these concepts and what measure specifications we do have to this group so that we can be thinking about using it in rural writing now just to be clear with everybody role writing or putting these measures into place would not occur until 2022 likely at the earliest and the um what we know about vaccination what we know about kobit will certainly change in that time but we wanted to bring forward proven vaccination to you to think about and you’ll see in subsequent slides we’re asking you to consider two different types of measures the first one will be for health care personnel vaccination and that will cover a broad range of the continuum of care and second patient vaccination which will be specific to esrd into the mips program it is not in the nursing home program and you could you might say well why not that’s possibly the most important one and it has to do with the authority for data collection so data is certainly being collected and will be looked at so i’m going to turn this over then to our colleagues at the cdc dan thank you so much for being on the line and then um i may have a couple more comments and alan levitt will lead the presentation from the cms point of view so dan thank you dan are you there you might be unmute i knew that they were on still nothing i see dan it just looks like we can’t hear him i don’t know is there any other is there anyone else from cdc that wants to speak to this or we can probably between ellen and i can start this can you hear me now there we go yes dan thank you i apologize for the delay uh thank you very much michelle uh in the next 20 minutes or so i’ll be introducing the national healthcare safety network or nhsn covet 19 vaccination tracking modules that were released just three weeks ago this is the work of a whole team of cdc’s division of healthcare quality promotion which operates nhsn in collaboration with the cdc subject matter experts particularly uh dr suchita patel and megan lindley cdc’s immunization services division i’ll cap the next slide so in next slide uh let me start by very briefly reviewing current data on the burden of covet 19 uh when we had to submit slides for this meeting at the end of the december the cumulative total of 18.9 million cases of covet 19 but just as of this weekend we now count over 22 million cases of coven similarly the average number of cases per day has increased from fifty seven thousand per hundred thousand population per day to seventy four thousand i’m sorry the seventy four cases per hundred thousand uh population as of this weekend and the total number of coven 19 deaths is increased from over uh 331 231 000 to over 371 000 deaths as of this weekend now something that has not changed is the age distribution of these deaths with 80 percent of deaths occurring in patients 65 or older next slide and as you know with just a level set there are two mrna-based vaccines currently authorized for use in the of note these vaccines are not approved by fda but rather authorized for emergency use there are additional vaccines in phase 3 trials and applications for authorizations for use of these vaccines are expected in the in this year vaccination requires two doses of these currently authorized vaccines recommended to be administered 21 days apart for pfizer biointact vaccine

and 28 days apart for the modern manufactured vaccine among the vaccines in phase 3 trials there’s at least one that requires only a single dose the pfizer vaccine is authorized for patients 16 years of age and older and the modern vaccine is authorized for patients 18 and older next slide now cdc’s advisory committee for immunization practices has recommended face allocation of vaccine due to current supply distribution and administration limitations you see here these uh four phases of that have been recommended in phase one uh it’s recommended for healthcare personnel and long-term care residents that’s phase 1a phase 1b frontline essential workers and persons 75 years of older phase 1c person 64 to 75 to 74 years and others however it’s important to know that the local jurisdictions states and their health departments may adjust these recommendations for their jurisdictions for example the state of georgia is now opening up vaccination eligibility to persons 65 to 74 but not other groups in phase 1c next slide now as with covid19 case counts vaccination counts are changing daily as of january 8th cdc now reports over 22 million doses of vaccine have been distributed to jurisdictions and nearly 6.7 million up from the 1.9 million listed here people have been vaccinated with the first dose now you may be familiar with the federal pharmacy partnership program for vaccinated long-term care residents and through this program there have been over 4 million doses of vaccine distributed nearly 700 000 persons and ltcs vaccinated now the majority of folks vaccinated by the pharmacy partnership program are long-term care residents but long-term care facility workers also can be eligible for vaccination through this program and that brings me to the next slide which has some key points on why vaccination coverage for healthcare personnel matters first vaccination can protect healthcare personnel from acquiring diseases themselves from patients because when healthcare personnel fall ill their absence of war from work can resolve disruptions of care for patients also vaccinations vaccination of healthcare personnel can prevent outbreaks of disease among patients in healthcare settings or residents in long-term care facilities we have much evidence of nosocomial transmission and outbreaks of measles mumps varicella influenza and pertussis and finally provider recommendations for vaccination i’m sorry provider vaccination is a predictor for vaccine uptake of patients in all ages next slide here’s some data on the burden of covet among health care personnel and as we’ve seen before these numbers continue to increase as of yesterday cdc now reports over 350 two thousand cases among health care personnel and one thousand two hundred and ten deaths among health care personnel next slide now there’s precedent for tracking health care personnel vaccination as a quality of care measure nqf0431 measures influenza vaccination in healthcare personnel it was first endorsed in 2012 the denominator used for this measure is all healthcare personnel who physically work in a facility for at least one day of the flu season between october 1st and march 31st the numerator for this measure is the number of healthcare personnel in the denominator who are vaccinated at this facility or elsewhere plus number with contraindications and number who declined vaccination nqf0431 is reported annually via cdc’s nhsn program by over 5000 facilities participating in cms’s hospital inpatient quality reporting program ltch hospital quality reporting program an inpatient rehabilitation facility quality reporting program nqf-0431 was formally utilized in reporting programs for ambulatory surgery centers outpatient dialysis facilities and inpatient psychiatric facilities next slide i’d like to make a few points about nhsn for folks that may not be as familiar with the system it’s a web-based system for monitoring healthcare-associated adverse events healthcare worker vaccinations and other preventive prevention practices it’s been operation in its current form since 2005 a time we replaced several predecessor cdc systems that have been used since the 1970s includes over 37 000 participating facilities in all 50 states once data are entered they’re available

in real time available for facility level clinical performance measurement improvement by facilities themselves and networks of facilities the data are also used by state health departments and cdc health surveillance for prevention activities and the data are used for public reporting of facility-specific data as in the case for nqf-0431 next slide here is just a table of the key facility types and the number of facilities enrolled in hsn of note among the long-term care facilities are included 15 400 sniffs next slide so that that background let’s get into some details about the covet 19 vaccination coverage modules which were initiated just uh the third week of december last year next slide now the nhsn covert 19 vaccination modules were created to collect weekly facility level vaccination coverage among initial priority groups for vaccination you’ve seen these are healthcare personnel residents of long-term care facilities and finally patients cared for by outpatient dialysis facilities and this module is not yet available but is planned to be introduced early this year now individual healthcare personnel or patient data are not being reported instead it’s the cumulative number of healthcare personnel or patients who’ve received coven-19 vaccination by vaccine type currently pfizer or moderna and dose first or second delivered either at this facility or elsewhere next slide and the purpose for collecting these data this time is to address a current public health need to track the progress of facility level vaccination coverage these data can be used by jurisdictions to target and address areas of low vaccine coverage and to assist federal planning by comparing vaccine coverage and actual in facilities to vaccine distribution but a key point is that currently these modules are optional so while cdc encourages jurisdictions to promote the use of these modules reporting as of today is currently voluntary next slide to give an overview of key aspects of the healthcare personnel modules as i mentioned the frequency is report is weekly reporting the denominator collected is the number of healthcare personnel currently eligible to work for at least one day during the reporting week similar to the influenza uh nqf manufacturer we heard about earlier and for the numerator uh although facilities report data weekly they’re not reporting incident vaccinations but rather the cumulative number of healthcare personnel or patients vaccinated to that date again similar to the influenza measure of cumulative vaccination over a season facilities can submit vaccination by several categories of healthcare personnel but by submitting by the uh by these categories is optional it is required to report the number of healthcare personnel with contraindications to vaccination but it’s optional to report other variables of interest such as healthcare personnel to decline vaccination unknown status of vaccination and documented history of tsar’s cov2 infection there are some additional questions about vaccine availability of the facility and incident adverse events next slide finally i’ll show some slides that represent the data collection modules themselves facilities enter their total number of healthcare personnel on a screen shown here it may subset this number based on the category of worker these worker categories are based on nhsn’s coven 19 staffing module from earlier last year next slide for long-term care facility the worker categories are a little bit different than for other facilities these healthcare personnel categories are based on the influenza vaccination modules again reporting by these categories is optional but the total is required next slide in this screen we show the data collection to distinguish the first and second doses of vaccination and it here you see the pfizer bioentec vaccine selected additional vaccines can be added as they are authorized for use again the total number of healthcare personnel vaccinations required but categorization is optional next slide and there’s data collection for the

other conditions mentioned contraindications declinations history of previous coven 19 vaccine next slide and finally i mentioned there are questions about vaccine supply which is not directly relevant to the discussion today but we’re designed to supplement our other vaccine supply tracking systems and next slide and finally a question about adverse events that’s really designed to encourage reporting to theirs the vaccine adverse event reporting system but also provides a measure of incident adverse events in that facility next slide and so that that’ll uh end this presentation uh but i think uh others uh will continue uh to talk about the specific uh nqf measures to be discussed today okay thank you dan this is alan levitt can we move ahead a couple of slides to perfect okay well thank you once again um i’m alan levitt for those who don’t know me i’m the medical officer in the division of chronic and post-acute care at cms and uh for the next few minutes i’m going to give you an overview of the quality measures we’ve developed in collaboration with dan and our nhsn colleagues regarding coven 19 vaccination and that’s muk2004 sars cov2 vaccination coverage among healthcare personnel which is under consideration for multiple settings in cms programs and a mach 2004 eight source cov2 vaccination coverage for patients in esrd facilities which is under consideration for the end state adrenal disease or etosart equip as we continue to meet the challenges of the cova 19 pandemic there are some important lessons we have learned so far including the importance of our public-private partnership a partnership best represented by the work we do here together at the map work that i’ve now had the honor to be the cms representative for the pac ltc work group for now my eighth year as i mentioned to the rural health work group last wednesday that’s why we’re here presenting these copic 19 vaccination measures to you to present and discuss measures under consideration that under normal circumstances we would likely not be proposing at this level of uncertainty but this past year has been far from normal circumstances and so i i wanted to thank the nqf staff once again for their understanding in allowing us to present these measures today and we understand their perspective in their preliminary analysis of these measures and and thank you sherry once again uh for that explanation let me go to the next slide please the first measure i’ll be discussing today is muk2004 which is rscob2 vaccination coverage among health care personnel when we first started considering with our nhsn colleagues approaches to publicly reporting covert 19 vaccination data this past spring we recognized that there would likely be evolving recommendations of vaccine administration such as conjunctions leading to exclusions for vaccination the frequency and timing of an initial vaccination and ultimately the frequency of re-vaccination to remain covert free first and foremost we should all be enormously thankful for the ingenuity of our scientists who developed in record time remarkably safe and efficacious vaccines as i mentioned last week the data on efficacy and safety of the covid19 vaccines are beyond what i think even the most optimistic of vaccine proponents could have ever expected however we are dealing with managing a pandemic in real time and recommendations regarding vaccine administration will likely evolve and so in collaboration with our nhsn colleagues we developed the healthcare personnel cova-19 vaccination measure that would have allow for flexibilities in vaccine administration the result of this measure is a measure of health care personnel vaccination coverage for your review today next slide please the nhsn is the measure steward because

they have successfully done these healthcare personnel vaccination measures before as dr budnitz just noted in his presentation this measure is nqf0431 influenza vaccination coverage among healthcare personnel he built on that success as our nhsn colleagues were able to develop data collection forms in their modules similar to those used in this measure but would also allow for any necessary flexibilities based on changes in vaccination requirements and administration over time as our rollout proceeds next slide next slide is an example of how 0431 the healthcare personnel flu vaccination measure gets currently publicly reported on our care compare websites this is an example from the inpatient rehab facilities you can see a comparison of staff uh flu vaccination rates over a flu season for three different facilities go to the next slide the next slide lists the uh federal programs by work group that you will be considering muk2004 for uh this afternoon for this upcoming rulemaking season so starting at 1 pm you will be discussing these measures for the six federal programs in the hospital work group and for those you in the pack ldc work group with me we will be discussing the measure for the three federal programs listed here go to the next slide the next slide describes the numerator and denominator for these measures the numerator is based on the data collected on the forms described by dr budnets earlier and allows for the flexibilities as we continue to learn more about how to successfully and safely vaccinate healthcare personnel but in summary we will be reporting the percent of eligible healthcare personnel working in that setting who are up to date with the current kovi 19 vaccination requirements whatever up to date might mean in the future next slide the measure will exclude those health care personnel with contributions to vaccination which will hopefully remain very few if adopted into our programs the measure would be initially calculated on a quarterly basis by the nhsn for public reporting on our cms compare websites for that applicable healthcare setting i do want to note that the reporting of data for the purposes of the necessary surveillance of vaccination efforts may be at a greater frequency especially initially during this rollout period but for the purposes of the calculation of these quality measures for the cms programs it would initially be calculated on a quarterly basis by the nhsn for the public reporting on these websites and as a reminder as dr schreiber already mentioned if these measures do get proposed and finalized in rulemaking they would likely be publicly reported we’d be looking at the earliest by this time next year let’s go to the next slide um this next measure on the consideration is muck twenty zero zero four eight uh which is saurus cov2 vaccination coverage for patients in end-stage renal disease facilities this measure is being considered for the yes sir to equip and once again would be stewarded by and collected through the nhsn as noted in the measure description this measure would track up-to-date cova-19 vaccination coverage of esrd patients next slide similar to the health care personnel covert 19 vaccination measure the numerator allows for the flexibilities as we continue to learn more about how to successfully and safely vaccinate the srd patients next slide exclusions for this measure would be similar to the health care personnel vaccination measure and will hopefully be minimal if adopted in the yes are equipped this measure would be initially calculated on a quarterly basis finally i’m going off the topic regarding these measures just to make a personal comment it’s not an official comment

official cms comment but it’s a personal comment on the on the hesitancy we have heard about in the news reports about healthcare personnel who are delaying to receive cover 19 vaccination or that you may have experienced in your your own roles as leaders in health care for almost a year now we’ve been in as was noted earlier national choir a national crisis a war against a worldwide viral pandemic pandemic that has affected our lives lies for those we love the lives of our patients that we care so much about as well as our livelihood we’ve had and continue to have as doctor buddhist points out far too many casualties in this pandemic but we are not just civilians who are helpless and are at risk here but we are also soldiers who have weapons that can fight and eradicate this virus and help us win this war against kobe 19. so please let’s all use these weapons at our disposal whether it’s wearing masks pbe practicing social distancing or now that we have safe and effective vaccines when it’s your turn please get vaccinated as well as encourage others around you to get vaccinated for yourselves for all of those you love including your patients and for our country now i’ll turn it back to sheri and the nqs staff for questions and comments uh but but also note that you’ll have time to ask questions and comments on these measures in each of the federal programs this afternoon thank you thank you alan thank you michelle and thank you dan for the presentation and remarks we’ll now open it up for questions and as well you can use the raise hand feature we have a question from aaron good morning or i guess good afternoon for some of us um one question that that stands out um that i’m sure we can talk about when we break into separate groups this afternoon but i wanted to raise with everybody um putting aside that they’re not in nhsn one of the provider categories that is represented here today is home health who also are included in uh the priority for health care personnel i wonder what thought cdc and cms have given to how do we track the home health worker vaccination first of all aaron thank you thank you for that comment and um the the inclusion or exclusion of you know any of the health care settings you know from the measures that were chosen is absolutely no reflection on the importance of the vaccination of the health care staff within that particular setting you know one of the other important lessons i think we you know we’ve learned here as well is uh besides the importance of the partnership that we have here is also the uh operationalizing uh what we’re trying to do and you know thinking early about things and you know what we can accomplish and what may be you know barriers uh uh to accomplishing uh such things and so when we take into account really what what settings to initially include in terms of this vaccination measure we take into account such things as enrollment within the nhsn itself and some the burden that may be in terms of either enrolling a healthcare survey setting or the burden on even our nhs and colleagues in terms of uh getting the setting in particular uh enrolled that doesn’t change the importance of vaccinations doesn’t change the importance of getting a data collected on it it’s really just a matter of in terms of these measures that we’re initially first looking at is you know where can we you know definitely be successful uh in this initial step while continuing to work with all the other settings in terms of looking towards uh being able to successfully publicly report um such data um including you know healthcare personnel vaccination measures for um home health or or for other health care settings or even looking at things such as flu vaccination and where healthcare personnel flu vaccination measures may be most important but again please don’t take this as a message that

the vaccination that setting is not important thank you so much next we have a question from janice thanks very much for the information and i have a couple of questions um and uh i like you would like to start off by um acknowledging the importance of vaccination and the importance of rolling out as quickly as possible the copa 19 vaccines i have a couple of questions one is that as you take a look at what institutions have to put in for their denominator my understanding is is that that denominator could change because not all employees are eligible and even if they are within a certain category saying a nursing category if they’re in administration they’re not patient facing um they are not eligible for the vaccine right now so there is um a number of uh issues um with what i would say is a changing denominator um as the vaccine rolls out um the second thing is is um my question is uh about the portal that’s being used um hospitals uh have been strongly instructed over the last couple of months that the hhs portal would be the portal that would be used for all um of our daily requirements from reporting and i see that you’re using the nhsn portal in this and i was wondering if you could comment about that and then third um again even though this is a critical vaccine and i in fact have received it and intend to receive my second in a very short period of time um it still remains uh under an eua um and an eua is different than being fda approved and i think that um that has that particular factor has really i had many health care institutions pause as to making the vaccine mandatory for employees and so those are sort of my um three questions happy to stop now to hear your uh thoughts so janice this is michelle i’ll start with a couple of them one is the data collection with the hhs versus the nhsn and we recognize that there could be potential challenges but we don’t think so because we are at least going to try hard to make sure that if uh the data is in a different area than nhsn that we can make sure that they communicate so thank you for raising that the second one is the question of the eua um and actually to your first question too recall that we are bringing this forward now for consideration for a measure that probably won’t be in effect until 2022 and we recognize that those numerator and denominators we kind of wrote it broadly you know for eligible uh people to have gotten the you know the vaccine to the you know the correct that um series of vaccines in other words we’re trying to leave this with some flexibility to be able to better define that as we continue writing measure specifications there’s nothing in this that says there is a mandate for vaccination although i think all of us would like to think that it is you know highly important to get vaccinated and certainly the percentage of the health care workers that are vaccinated is as well as patients is clearly important but none of this implies a mandate on the other hand we think it is absolutely essential to be tracking vaccination for um certainly healthcare personnel and ultimately for all patients we couldn’t do it in the means we had available to us right now but we would envision over time that we will do this in a more widespread fashion so we are bringing this for comment now recognizing that some things may change and and i think probably to the last point is i don’t think that we have any information right now on whether this is going to need to be an annual or triangle or or whatever you know we still um we still don’t have sufficient information on um how long uh an individual uh will remain uh you know with certain uh i guess antibodies or uh antibody recall so so that it might be a one-and-done shot and you know you come back in ten years or you might come back

um annually so um and god willing we hope that’s true yeah but um but a lot of uh a lot of moving parts here dan allen did you want to make any comments on hhs versus nhsn reporting oh okay okay we do have three other questions that are in queue the first is from taigel hi there um so my question and you know i totally appreciate these are very early days for these measures but as you’re thinking about your planning as you go forward how are you anticipating trying to bring an equity lens to these particular measures particularly when i think about the healthcare workforce for example we have survey data showing there’s very different different attitudes towards taking the vaccine across job types and i think you know has mentioned that those are optional fields in nhsn but i’m thinking that that’s going to be an important thing to follow to then try to do quality improvement to narrow some of those gaps on the workforce side and i’m sure on the patient side as well we would be seeing those kinds of gaps so just curious what your thoughts are on that front i mean i think from our point of view this is the opportunity to again stratify the data to be looking at that and we encourage every organization to be doing that dan um or alan i don’t know if you want to comment from an nhsn point of view if you guys are looking at this data stratified um for equity so yes thank you and thank you for the question um while our initial emphasis uh has been on getting total vaccination data uh and these additional data elements were made optional initially uh date elements can be made required in the future as we uh ensure that data collection is continuing and if it may become the whole form might be become required in the future so these optional or required data lines can be can be altered in the coming year or years next we have a question for mckean thanks and uh thanks stan and alan and michelle for the introductory comments uh just a clarifying question uh this uh employee vaccination measure is proposed for both the inpatient and outpatient quality reporting programs there will be a subset of employees who work in both inpatient and ambulatory spaces how are you thinking about the reporting of the data for those employees that might overlap i i know that this issue has been one that’s come up with respect to the flu vaccination measure over time so can you talk a little bit about how that would be handled i think at this point in time they’re counted in whatever facilities so the facility is providing the report so for example um in the flu vaccination it’s anybody who has worked in your facility for at least one day in that year if you worked in three different facilities each facility would be able to list you as having been there and gotten credit for the fact that you had a flu vaccination i think the same thing would be would hold true here for kova dan i’ll i’ll ask you to confirm all right yes uh thank you michelle that that is our thinking and the the goal of these uh facility-based vaccination modules is to gauge protection of the fellow workers and residents or patients at the facility so while it might appear to be quote double counting having that same worker who works at multiple facilities being counted in each facility it’s to assess the you know coverage and protection in that facility so in other words you might have to count that same employee multiple times in the denominator but you can also claim credit for them in the numerator yes okay that helps thank you it’s in uder maybe one more question the next question is from mike well i’d i’d echo the comments of gratitude for the proactive approach on this very important topic i just wanted to get a little clarification on the time frame for reporting i think if i read correctly weekly reporting of a denominator can certainly be a significant burden of reporting and thoughts on weekly versus a longer time frame of reporting from the program point of view it will be quarterly reporting but from the having to report proven

vaccine data to nhsn or frankly hhs or wherever it is going to mandate being reported um dan i i will ask you but i think that certainly as the vaccine rolls out there’s the absolute desire to have data that’s very timely quarterly wouldn’t be acceptable dan do you want to comment yes thank you so as we saw with the numbers and the pandemic uh advancing and changing so quickly we thought it’s important to collect data weekly uh initially but again that may change in the future and also for reporting that could change to be just based on a quarterly report of the denominator uh in a cumulative count of vaccination over the quarter if that’s the interval for the numerator as well great thank you well this is matt um thank you um dr schreiber alan dan once again uh for the presentation and for the question and answer session and thank you to the work group members uh for your participation and questions with this i will state that as we break off this afternoon uh there will be some additional individually some individuals who will be participating from cdc during those portions of the measure evaluations um so there will be some opportunity potentially for some further questions or clarification if needed i do want to recognize it’s 12 30 so we will be breaking for lunch and reconvening back in our separate work group meetings at 1pm if you look into the chat box what you’ll find is that there are now being posted uh two separate links for for the work uh for the work groups one for hospital one for pac ltc so keep keep an eye on that um as well so those will be the links you’ll use to come back to uh the 1pm separate individual work group um and with that uh we will go ahead and hey matt i’m sorry can i make one last comment yes please so this is uh michelle from cms i just wanted to thank the post acute care team i won’t be on your call this afternoon because i’ll be with the hospital team so sean and mckean you’re still stuck with me but for the post-acute care team ellen levitt will be leading it from cms’s point of view and he obviously is a tremendous expert in this area but i wanted to just take a moment to thank all of the members of the yaptak team and thank you for your continued participation so thank you matt sorry to have interrupted oh it’s not a problem it’s not a problem um i will i will go ahead and just mention again uh that you’ll have those those links that’s provided in the chat um available to you and also if you could dial in just a few minutes early again just to make sure that everything is up and running you’re good to go uh so that we can sort of kick off right right at the top of the hour uh but thank you all very much for the morning sessions the joint session we will be breaking away and will we be reconvening at one o’clock but please try to log in just a little bit earlier thank you all and this is amy just very quickly if you are on the phone and you don’t have access to the chat the dial-ins and information for this afternoon’s meetings are also available in the agenda which is on our website you can either go to we have a main nqf calendar that lists each of the events or you can also visit the project pages so if you go top right select about us and pick project pages you can go to map hospital or map pack ltc to get the information thank you everyone you