Aligning Quality Measures Across CMS - the Universal Foundation

Aligning Quality Measures Across CMS - the Universal Foundation

To further the goals of alignment and burden reduction, CMS has begun streamlining quality measures across quality programs for the adult and child populations. This “Universal Foundation” of quality measures focuses provider attention, reduces burden, prioritizes development of interoperable, digital quality measures, allows for comparisons across programs, and helps identify measurement gaps. The development and implementation of the Adult and Child Universal Foundation Measures promotes the highest quality, safest care as we all work together on these critical quality areas. As CMS moves forward with the Universal Foundation, we will be working to identify foundational measures in other specific settings and populations to support further measure alignment across CMS programs as applicable.

Selection Criteria for the Universal Foundation:

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

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

Universal Foundation:

DomainMeasure Identification Number and Name
Wellness and prevention139: Colorectal cancer screening
93: Breast cancer screening
26: Adult immunization status 
Chronic conditions167: Controlling high blood pressure
204: Hemoglobin A1c poor control (>9%)
Behavioral health672: Screening for depression and follow-up plan
394: Initiation and engagement of substance use disorder treatment
Seamless care coordination561 or 44: Plan all-cause readmissions or all-cause hospital readmissions
Person-centered care158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)
   Social Drivers of Health    1662/1664: Screening for social drivers of health
Domain    Measure Identification Number and Name
Wellness and prevention761 and 123: Well-child visits (well-child visits in the first 30 months of life; child and adolescent well-care visits)
124 and 363: Immunization (childhood immunization status; immunizations for adolescents)
760: Weight assessment and counseling for nutrition and physical activity for children and adolescents
897: Oral evaluation, dental services
Chronic conditions80: Asthma medication ratio (reflects appropriate medication management of asthma) 
Behavioral health672: Screening for depression and follow-up plan
268: Follow-up after hospitalization for mental illness
264: Follow-up after emergency department visit for substance use
743: Use of first-line psychosocial care for children and adolescents on antipsychotics 
271: Follow-up care for children prescribed attention deficit-hyperactivity disorder medicine 
Person-centered care158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures (CAHPS)

Additional Universal Measure Sets:

To assess care provided across the continuum of care experienced by individuals, including additional measures beyond those captured in the Adult and Pediatric Universal Foundation are necessary. 

As of 2025, CMS has developed Universal Foundation measure sets for individuals receiving care in the hospital setting, post-acute care setting, and who are currently pregnant. 

DomainMeasure Identification Number and Name
Chronic Conditions Equity696: Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure 
1664: Screening for Social Drivers of Health
Person-Centered Care338: Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey
162: Outpatient and Ambulatory Surgery CAHPS Survey
 
Safety460: National Healthcare Safety Network (NHSN) Central Line Associated Bloodstream Infection (CLABSI) Outcome Measure
459: NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
463: NHSN Facility-Wide Inpatient Hospital-onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure
1: NHSN Surgical Site Infection (SSI)
462: NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
135: Patient Safety Indicators (PSI) 90
678: Severe Sepsis and Septic Shock Management Bundle
1633: Severe Obstetric Complications
Seamless care coordination356: Hybrid Hospital-Wide All-Cause Readmission 
427: Median Time from ED Arrival to ED Departure for Discharged ED Patients
DomainMeasure Identification Number and Name
Behavioral Health522: Percent of Residents Who Have Symptoms of Depression (Long Stay)
 
Person-Centered Care1698: Discharge Function Score
154: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey
Safety225: Drug Regimen Review Conducted with Follow-Up for Identified Issues-PAC 
520: Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay)
680: Skilled Nursing Facility Healthcare-Associated Infections (SNF HAI) Requiring Hospitalization 
121: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
471: Number of Hospitalizations per 1,000 Long Stay Resident Day
Seamless care coordination575: Potentially Preventable 30-Day Post-Discharge Readmission Measure
210: Discharge to Community-Post Acute Care (PAC)
728: Transfer of Health Information to the Provider Post-Acute Care (PAC)
727: Transfer of Health Information to the Patient Post-Acute Care (PAC)
DomainMeasure Identification Number and Name
Safety418: Maternal Morbidity Structural Measure
1633: Severe Obstetric Complications (eCQM)
508: Cesarean Birth (LRCD-CH/ eCQM)
Wellness and Prevention581: Prenatal and Postpartum Care: Postpartum Care (PPC-AD)
582: Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-CH)

The Universal Foundation: Next Steps

Annually, CMS reviews the Universal Foundation measure sets to ensure the sets continue to meet the selection criteria, identify and fill measure gaps, and reflect the healthcare journey. CMS will solicit feedback on the Universal Foundation through comments, rulemaking, listening sessions, or other forums. Feedback may result in: 

  • Measures being replaced or removed when goals are met
  • Measures being added to assess quality across the care journey
  • CMMI continuing to test new and innovative measures

Send feedback to QualityStrategy@cms.hhs.gov.

Page Last Modified:
02/26/2025 07:30 PM
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