78 | PROTOCOL TWO
Step 4: Complete the Detailed Review of Measures
WORKSHEET 2.2
WORKSHEET 2.11
WORKSHEET 2.9
WORKSHEET 2.10
Resource for Activity 2, Step 4
Worksheet 2.2. Performance Measure
Validation Template
• Provide a template for documenting
audit specifications for the validation
components of each performance
measure listed in Worksheet 2.1.,
and to assess the MCP’s
measurement and reporting process
for each component
Worksheet 2.9. Policies, Data, and
Information Used to Produce Measures:
Review Checklist
• Provides a checklist that tracks
documents and data used to assess
the accuracy of the MCP’s
performance measure calculations
Worksheet 2.10. Measure Validation
Findings
• Provides a template for documenting
adherence to guidance for the
denominator; programming logic,
source code, and calculations;
identifying medical events; exclusion
criteria; population estimates;
identifying the at-risk population;
inclusion of qualifying events in the
numerators; and medical record data
in the numerator
Worksheet 2.11. Interview Guide for
Assessing Processes and Procedures
Used to Produce Numerators and
Denominators
• Provides a list of interview questions
that can be tailored to supplement
findings recorded in Worksheet 2.10
For performance measures requiring
medical record review, please use
Worksheet 2.3. Medical Record Review
Validation Tool. The EQRO should
validate the results of the medical record
review for 30 enrollees who met the
numerator requirements for at least two
measures. For more information, refer to
Activity 1, Step 4.
In Step 4, the EQRO determines the extent to which the
MCP correctly used the technical specifications to produce
accurate performance measure results. All validation
components should be addressed during this step using
Worksheet 2.2. Performance Measure Validation
Template (or similar tool).
To ensure the integrity and comparability of the
performance measures, the EQRO should pay special
attention to factors affecting the accuracy and
completeness of the denominators and numerators. For
example, the EQRO should assess whether the MCP used
the appropriate data and methods to identify the entire
eligible population for the denominator (including linkage
of data from separate sources, application of inclusions
and exclusions, and creation of complex episodes, where
applicable). In addition, the EQRO should determine
whether the MCP correctly identified and assessed
qualifying medical events for the numerator to include all
appropriate events, while excluding events that do not
qualify. The EQRO should determine whether the
numerators and denominators were calculated
appropriately based on all applicable codes (such as
diagnoses, procedures, and prescription drugs) and all
available data sources (such as membership/enrollment
data, claim/encounter data, provider data, utilization or
medical management information systems data, or data
extracted from medical records).