The Weekly Quality Brief: eCQM Validation, Patient Safety Structural Measure Attestation, and PRO-PM Submission Updates (February 19, 2026)
The Weekly Quality Brief
This episode covers questions reviewed during the February 19, 2026 Quality Academy Weekly Q&A session, with discussion focused on validation processes, reporting guidance, and upcoming measure requirements.
eCQM Validation and Audit Process
- How CMS is expected to validate eCQMs going forward
- Differences between historical validation feedback and future scoring implications
- Clarification that “100% accepted” submission status confirms file format, not data accuracy
- Common mapping and documentation issues that may not be identified at submission
CLABSI/CAUTI Validation and Oncology Location Reporting
- Use of the same hospital sample across eCQM and HAI validation programs
- Reporting expectations for oncology-specific locations under NHSN definitions
- Reference documents hospitals can use to confirm applicable locations
Patient Safety Structural Measure (PSSM) Attestation
- Five required safety domains included in the measure
- Annual NHSN attestation process and April 1–15 submission window
- Facility-level scoring and public reporting approach under shared CCNs
Mortality Measure Exclusions
- Hospice exclusions in hybrid and claims-based mortality methodologies
- CMS use of claims data for exclusions rather than QRDA submission
PC Measure and Joint Commission Updates
- Status of known mapping issues affecting PCO7 public reporting
- Continued unresolved specification issue for co-located NICUs in PCO6
ED and Outpatient Reporting Questions
- Discharge code abstraction guidance for ED outpatients admitted to observation
- Timeline for the Emergency Care Access and Timeliness eCQM (voluntary in 2027, required in 2028)
PRO-PM Submission and Reporting
- CMS confirmation that hospitals may submit PRO-PM data via both CSV upload and manual entry
- Interim reporting timeline for THA/TKA PRO-PM pre-op survey volumes (spring 2026 HSR)
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