CollaboRATE Shared Decision-Making Tool for Ambulatory or Outpatient Surgery Patients (Surgical CollaboRATE OAS-PM)

This measure appears to be a large burden on the facility where the procedure will be performed.  The shared decision making process is usually conducted in the physician office, not in the surgery center.  The surgery center would become responsible for assessing the patient's thoughts on the process at a time that the patient is preparing to enter the operating room.  This could delay care and reduce efficiencies.  If this were to be implemented, it would be better assessed at the site of decision making. 

The ACS appreciates the opportunity to receive feedback on this measure as well as reply to issues that have been raised in the public comments and during the Pre-Rulemaking Measure Review (PRMR) Public Listening Session held on January 6, 2026, our comments are as follows.

• Importance – Shared Decision Making (SDM) is important and focusing on SDM is the right thing to do for patients. It is associated with improvements in health and surgical outcomes, patient satisfaction, and reductions in unnecessary spending. In addition, 33% of patients report inadequate SDM demonstrating that there is substantial room for improvement.

   

• Burden - The CollaboRATE survey includes 3 items and takes patients approximately 30 seconds to complete prior to the procedure, making the completion of this tool low burden in comparison to other patient-reported outcome measures (PROMs). Other PROMs used in CMS outpatient and ambulatory programs often include more questions and/or must be administered pre- and postoperatively. Because CollaboRATE is a preoperative survey it does not substantially overlap with the 3 post-operative surveys already included in CMS programs.

   

  It is also important to note that the need for a measure on shared decision should outweigh many of the operational concerns that have been expressed. We see CMS’ prioritization of patient-reported outcomes (PROs)/ patient-reported outcome performance measures (PRO-PMs) and the expansion of this inventory as an opportunity to gain a better understanding of care from the patient’s perspective, which has been a gap for many years. With the implementation of existing PRO-PMs in CMS programs, facilities have had to design workflows around collecting these data from patients—ultimately opening the door to future PRO-PMs that represent areas of care that are important to patients.

   

• Feasibility - CollaboRATE has demonstrated usability through multiple mechanisms. Previous studies have administered the tool through regular mail, email, computer or web interface, telephone interviews, SMS text messages, paper surveys, cloud-based platforms, and EHR integration. In addition to the multiple options for administering the survey, CollaboRATE has been translated into multiple languages and is available in forms for patients with special considerations such as a caretaker or surrogate decision-maker. The ACS has demonstrated the feasibility of administering PROMs in a voluntary, opt-in scenario in surgical practices. Ultimately 30,000 patients from 977 surgeons and 65 facilities participated in this feasibility study. The measure as designed is flexible so that the instrument can be implemented in a way that matches ongoing implementation of other PRO's in these settings.

   

• Site of Attribution - Surgical quality is a team sport, and requires a well-functioning team founded on an institutional culture of safety and high-reliability. Assigning the site of attribution at the facility makes sense for the same reason that the facility makes sense as the site of attribution for other outcomes such as hospital transfer, cataract and knee outcomes, and ED visits after a colonoscopy. This is also demonstrated in the Inpatient Quality Reporting (IQR) and Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA PRO-PM) where the facility collects the data from patients on surgical care. Many of the existing facility-based measures are more attributable to surgeon skill, perioperative decision making and risk stratification, than they are to the building. Yet payors, patients, and referral networks are increasingly recognizing the facility’s role as the site where the entire team comes together to provide care, and its role as a driver of quality.

   

  The ACS also evaluated the reliability of the CollaboRATE tool at the physician versus facility level, and results demonstrated that CollaboRATE had a higher median reliability score than when used at the facility level in comparison to the surgeon level. This was primarily driven by the number of responses required to achieve adequate reliability, which was more likely to be achieved at the facility level than at the surgeon-level.

   

• CollaboRATE Compared to Other PROMS: The ACS conducted a study that reviewed the performance and feasibility of implementing two PROMs focused on SDM, CollaboRATE and the 9-item Shared Decision Making Questionaire (SDM-Q-9). The study assessed how these measures performed in the inpatient setting and also how the key performance indicators of the PROMs changed when the population was limited to only patients who underwent ambulatory procedures. This study determined that patient-reported SDM, particularly measured by CollaboRATE, could be a feasible performance measure for ambulatory surgery by promoting patient-centered care, including procedures with low complication risks.

   

• Focus on Distribution of CollaboRATE: To further reduce barriers to implementation of this important measure, this MUC focuses on the rate at which a facility distributes the CollaboRATE tool. We envision this as the first step toward widespread adoption in the ASCQR and Hospital OQR programs, with a path toward future pay-for-performance use. However, at this time, with the focus on distributing the PROM rather than collecting a facility’s performance score achieving a “high score” on this measure should attainable. We designed the measure in this way to highlight the importance of SDM and allow facilities time to get accustomed to incorporating the tool into their workflow and to gain familiarity with the measure before scoring the measure for performance.

I can't ascertain how this one tool will provide valuable intel to providers re: quality of care and patient perception.  

Although the CollaboRATE survey instrument solicits valuable information from patients, it is designed to address shared decision-making between patient and surgeon and to be implemented by a surgeon via the surgeon’s office structures of care. Thus it is not appropriate as a measure of facilities — ASCs or HOPDs. The facilities are ill-equipped to implement such a measure, which would have to be done in its communications with a patient leading up to surgery, or in the immediate preoperative period at the facility, a stressful time at which the patient is probably unable to answer thoughtfully the questions in the survey instrument. 
This measure, intended by the measure steward to reflect quality of care on the part of the surgeon, does not reflect facility care and should not be used to measure such facilities. 

By adding another survey with the proposed CollaboRATE shared decision-making - would be adding yet another survey   for hospitals to request  patients complete - That means  one patient could get could get an HCAHPS, THA/TKA PRO PM   an  Information PRO-OM and this new survey - This places burden on the  facilities to try and get the  patient's to complete these surveys.    Many patients do not want o complete  one or any  survey-   Adding more surveys will result in decrease responsiveness from the patients overall.  They may answer the first one but not subsequent.  

Dear Members of the 2025-2026 Pre-Rulemaking Measure Review (PRMR) Hospital Recommendation Committee: 

The undersigned organizations write to express our support for the inclusion of the CollaboRATE Shared Decision-Making Tool for Ambulatory or Outpatient Surgery Patients (Surgical CollaboRATE OAS-PRO-PM) (MUC 2025-023) in the CMS Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgery Center Quality Reporting (ASCQR) Programs. The CollaboRATE Shared Decision-Making Tool for Outpatient or Ambulatory Surgery Patients measure was developed to assess the quality of patients’ shared decision-making (SDM) for surgery in the ambulatory setting to improve patient-centricity, patient outcomes, and unnecessary care.

The landscape of surgical care delivery is rapidly evolving. Approximately 80% of elective surgical procedures are now performed—or are expected to be performed—in outpatient or ambulatory settings, including Ambulatory Surgical Centers (ASCs).¹ Additionally, the recent elimination of the Inpatient Only List² will further expand the volume and type of procedures that will be performed in the outpatient setting. Procedures traditionally performed in the outpatient setting are lower risk with shorter episodes of care and fewer adverse events. Yet, ASCQR and OQR continue to rely on adverse event complication-based measures as the primary metric for assessing quality of care for reimbursement. 

There is a clear need for the development of more patient-centric measures to focus on the aspects of care that are meaningful to patients and their caregivers in outpatient settings outside of outcome measures that capture rare events. Patient-centric measures such as patient-reported outcome measures (PROMs), patient-reported outcome performance measures (PRO-PMs), and tools that assess SDM and patient goal attainment can be more meaningful to patients and referring physicians in ambulatory and outpatient settings. These measures can capture differences in care quality that are important to patients, such as whether patients felt understood, whether surgical decisions aligned with their personal goals, and help the surgical team organize care around delivering on patient goals. Research has demonstrated that SDM is associated with better patient satisfaction, improved outcomes, reductions in emergency room visits, reduced unnecessary healthcare use, and reduced patient regret .^3-7 Importantly, patients who experienced complications have reported lower-quality decision-making conversations, underscoring the link between communication and outcomes. 

The Surgical CollaboRATE OAS-PRO-PM (MUC 2025-023) reinforces the importance of SDM between the patient and surgeon prior to a surgical procedure in an ambulatory surgery center or hospital outpatient department and is a positive step towards a more patient-centric quality framework. While this is a new measure, it uses the CollaboRATE tool which was rigorously developed using cognitive interviews, modified based on patient feedback during pilot testing, and was initially validated using simulated clinical scenarios.^8-9 It has since been studied and used successfully in multiple surgical and medical settings including outpatient clinics and ambulatory surgical settings.^5,7,9-17 CollaboRATE is a validated, low-burden, three-question survey designed to assess the quality of SDM from the patient’s perspective. This measure focuses on the rate at which a facility distributes the CollaboRATE tool, in order to incentivize an environment that highlights the need for discussions around patient goals and appropriateness of surgical care. The tool includes the following questions which should be privately administered prior to surgery, preferably within 24-48 hours of the clinical encounter: 

1. How much effort was made to help you understand your health issues?
2. How much effort was made to listen to the things that matter most to you about your health issues?
3. How much effort was made to include what matters most to you in choosing what to do next? 

It is critical to emphasize that the CollaboRATE tool can be completed by patients with little burden, in under 30 seconds, and feasibly administered by a facility without expending additional resources. CMS has taken steps towards implementation of other PRO-PMs in the ASCQR and Hospital OQR programs with the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (PRO-PM) (Information Transfer PRO-PM) and Total Hip Arthroplasty / Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure (THA/TKA PRO-PM), which has pushed facilities to implement the infrastructure to administer, collect, and report PRO-PMs. Not only does this highlight the importance of these patient-centric measures, but it also creates a path forward for the implementation of additional PRO-PMs that cover the patient’s full episode of care with little excess cost and burden on the facility. Ultimately, the addition of the Surgical CollaboRATE OAS-PRO-PM is in alignment both conceptually and practically with the existing PRO-PMs and incorporates assessments of another important aspect of care that aligns the individualized decision to operate with patient goals. 

The undersigned organizations appreciate the opportunity to share our support for the inclusion of the Surgical CollaboRATE OAS-PRO-PM in the ASCQR and Hospital OQR programs. This measure accounts for a critical step in surgical decision-making and understanding what is important to patients prior to their surgical procedure, which is lacking in both outpatient quality programs. We believe this measure not only is in alignment with the other PRO-PMs that CMS has implemented in outpatient care but will also be another important step towards creating value based on what is meaningful to patients and their caregivers. 

Sincerely,  

American College of Surgeons (ACS)

American Association for the Surgery of Trauma

The American Delirium Society

American Geriatrics Society (AGS)

Association of periOperative Registered Nurses (AORN)

Hartford Institute of Geriatric Nursing (HIGN) at NYU Rory Meyers College of Nursing

The John A. Hartford Foundation

National Association of Social Workers (NASW)

Nurses Improving Care for Healthsystem Elders (NICHE)

Society of Surgical Oncology (SSO)

Dear Members of the 2025-2026 Pre-Rulemaking Measure Review (PRMR) Hospital Recommendation Committee: 

On behalf of the over 90,000 members of the American College of Surgeons (ACS), we write to express our support for the adoption of the CollaboRATE Shared Decision-Making Tool for Outpatient or Ambulatory Surgery Patients measure (MUC2025-023) in the Ambulatory Surgical Center Quality Reporting (ASCQR) and Hospital Outpatient Quality Reporting (OQR) programs. The CollaboRATE Shared Decision-Making Tool for Outpatient or Ambulatory Surgery Patients measure was developed to assess the quality of patients’ shared decision-making (SDM) for surgery in the ambulatory setting to improve patient-centricity, patient outcomes, and unnecessary care. 

The landscape of surgical care delivery is rapidly evolving. With approximately 80% of elective surgical procedures being performed—or are expected to be performed—in hospital outpatient departments (HOPDs) or ambulatory surgery centers (ASCs).¹ This will only continue to increase as CMS moves to phase out the procedures on the Inpatient Only List (IPO list).² Because of this shift, a change in perspective is necessary to effectively assess the quality of surgical care in outpatient settings. 

ASCQR and OQR rely on adverse event, complication-based measures as the primary metric for assessing quality of care for reimbursement, however, there is a clear need for the development of measures that focus on aspects of care that are meaningful to patients and their caregivers in outpatient settings. In many cases, patients must be low risk to be eligible for outpatient surgical care leading to less variation in outcomes, lower risk procedures, and shorter episodes of care in HOPDs and ASCs. While still important to track, adverse events are rare, making it difficult to use to distinguish care. When patients, their primary care providers, or Accountable Care Organizations (ACO)/Medicare Advantage (MA) plans attempt to refer care to a care team and a facility, most PCPs refer based on longstanding personal relationships, while ACOs push referrals based on narrowed networks due to cost and avoidable harms. The results have frustrated savings efforts since most care teams and facilities will appear indistinguishable. Given the low frequency of adverse events, the next generation of quality measures for the ambulatory setting should be more patient-centered and tied to the condition and surgical procedures under consideration. 

Patient-reported outcomes (PROs), patient-reported outcome performance measures (PRO-PMs), and tools that assess SDM can be more appropriate and informative in outpatient and ambulatory settings. These measures can capture meaningful differences in care quality from the patient perspective, such as whether patients understood or felt understood and whether surgical decisions aligned with their personal goals. This helps the surgical team organize care around the patient’s goals. Research has shown that SDM is associated with better patient satisfaction, improved outcomes, reductions in emergency room visits, reduced unnecessary healthcare use, and reduced patient’s post-operative regret about the decision to have surgery.^3-7 Importantly, patients who experienced complications have reported lower-quality decision-making conversations, underscoring the link between communication and outcomes. 

CMS has made an effort to incorporate patient experience and other PRO-PMs in the Hospital OQR and ASCQR programs with the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS), Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (PRO-PM) (Information Transfer PRO-PM), and Total Hip Arthroplasty / Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure (THA/TKA PRO-PM). These measures collect important information about experience and a safe recovery, but a gap still exists in highlighting the need for SDM and patient goal setting conversation prior to surgery. From the ACS’ perspective, SDM should be a top priority for CMS as it allows for the assessment and promotion of alignment between an individualized decision to operate and patient goals.

The Surgical CollaboRATE OAS-PRO-PM (MUC 2025-023) reinforces the importance of SDM between the patient and surgeon prior to a surgical procedure in an ambulatory surgery center or outpatient hospital department and is a positive step towards more a patient-centric quality framework in these settings. This measure uses the CollaboRATE tool which was rigorously developed using cognitive interviews, modified based on patient feedback during pilot testing, and was initially validated using simulated clinical scenarios.^8-9 It has since been studied and used successfully in multiple surgical and medical settings including outpatient clinics and ambulatory surgical settings.^5,7,9-17 The ACS also conducted a study that demonstrated the reliability of the CollaboRATE tool and the feasibility of administration across surgical specialties and settings. From 2020-2023, the CollaboRATE instrument was administered to 30,000 patients from 977 surgeons at 65 sites. During this study, CollaboRATE was tested side by side against other measures of SDM and was assessed for reliability both as a surgeon and facility metric. The results of this analysis showed highest reliability when calculated at the facility level, as well as improved likelihood of meeting reliability volume thresholds.¹⁸

It is important to emphasis that CollaboRATE is a validated, low-burden, three-question survey designed to assess the quality of SDM from the patient’s perspective, which can be completed under 30 seconds. In comparison to PRO-PMs in CMS programs, this tool requires significantly less patient work due to the minimal number of questions. The tool also only requires pre-operative administration, increasing feasibility in comparison to PRO-PMs that require pre- and post-operative survey follow up. The tool includes the following questions which should be privately administered prior to surgery:

1. How much effort was made to help you understand your health issues?
2. How much effort was made to listen to the things that matter most to you about your health issues?
3. How much effort was made to include what matters most to you in choosing what to do next? 

To further reduce barriers to implementation of this important measure, this MUC focuses on the rate at which a facility distributes the CollaboRATE tool. We envision this as the first step toward widespread adoption in the ASCQR and Hospital OQR programs, with a path toward future pay-for-performance use. This will allow facilities to get accustomed to incorporating the tool into their workflow and to gain familiarity with the measure before scoring the measure for performance. 

It is critical to reiterate that this tool can be completed by patients with little burden, in under 30 seconds, and feasibly administered without expending additional resources. As stated, CMS has taken steps toward implementation of other PRO-PMs in the ASCQR and Hospital OQR programs with the Information Transfer PRO-PM and THA/TKA PRO-PM, which has pushed facilities to implement the infrastructure to administer, collect, and report PRO-PMs. Not only does this highlight the importance of these patient-centric measures, but it also creates a path forward for the implementation of additional PRO-PMs that cover the patient’s full episode of care with little excess cost and burden on the facility. Ultimately, the addition of the Surgical CollaboRATE OAS-PRO-PM is in alignment both conceptually and practically with the existing PRO-PMs and incorporates assessments of another important aspect of care that aligns the individualized decision to operate with patient goals. 

In conclusion, this measure aligns with CMS’s vision for person-centered care and will drive implementation of the CollaboRATE tool with the intent of improving the quality and patient-centeredness in the ambulatory and outpatient settings. The measure accounts for a critical step in SDM and understanding what is important to patients prior to their surgical procedure, which is lacking in both outpatient quality programs. To that end, the measure should be incorporated into both the ASCQR and the Hospital OQR so that patients can compare care between the two settings. Without important patient-centered and actionable data, the ASCQR and Hospital OQR programs offer limited opportunity for quality improvement in ASCs and outpatient surgery.

The ACS appreciates your consideration and welcomes the opportunity to provide additional information or participate further in the review process. Please contact Jill Sage, Chief of Quality Affairs, at [email protected] with questions. 

Sincerely, 

Patricia L. Turner, MD, MBA, FACS 

Executive Director and CEO

It is important for surgeons to have these discussions with their patients.  However, in small, rural, and medically-underserved communities, the hospitals do not employ their providers.  This measure holds hospitals accountable for discussions the providers should be having with their patients :  "The developer reports facility-level and surgeon-level reliability but concludes that due to low surgeon-level reliability, the measure will be aggregated at the facility level."  This also creates challenges for hospitals because the survey is to be administered within one week of the discussion.  When it is an elective surgery, the hospitals have no way to know, necessarily, when those discussions may have occurred (hospital EMRs are not linked to clinical practices).  I feel that the cost and burden of implementation for this measure outweigh the benefits specific to hospital-derived outcomes. Thank you. 

The American Geriatrics Society (AGS) supports the inclusion of MUC2025-023 for the CollaboRATE Shared Decision-Making Tool for Ambulatory or Outpatient Surgery Patients (Surgical CollaboRATE OAS-PM) in the Centers for Medicare and Medicaid Services (CMS) programs. 

An important framework for how geriatrics health professionals care for older adults is the Geriatrics 5Ms (DOI: 10.1111/jgs.14979). Our members are on the frontlines of caring for older Americans, many of whom are living with multimorbidity, advanced illness, and/or with complicated biopsychosocial issues. The Geriatrics 5Ms informed the development of the 4Ms of age-friendly care (What Matters, Medications, Mentation, and Mobility) of the Age-Friendly Health Systems movement which seeks to reimagine the 21st century health system so as to provide care that is age-friendly, respects the goals and preferences of the older adult, and meaningfully and substantially includes family caregivers in the plan of care (DOI: 10.1016/j.hjdsi.2017.05.005).
 

We believe the Surgical CollaboRATE OAS-PM captures valuable information that is related to age-friendly care and provides patients the opportunity to share whether they are included in the decision-making process and whether the care received aligns with what matters most to them. The measure is also simple to administer and would support care teams in understanding the degree to which they are engaging in shared decision-making, an important part of ensuring care is meaningful and effective for patients, their families, and care partners. 

Bon Secours Mercy Health is not supportive of the CollaborRATE Shared Decision Making Tool For ASC and/or OP Surgery Patients as it is currently presented.  Patients experiencing ambulatory or outpatient surgery may be surveyed for THA/TKA PRO PM, Information Transfer PRO-PM and Outpatient and Ambulatory Surgery (OAS CAHPS).  Patients are at risk for respondent fatigue and an additional survey adds to the potential for early termination of participation or less thoughtful responses and non-response.

Bon Secours Mercy Health encourages a thoughtful review of all surveys and reporting requirements to ensure response rates that result in meaningful data.  Additionally, a consistent approach to risk stratify for likelihood for survey response is desired.

The AHA recommends against inclusion of this measure into the OQR and ASCQR at this time. The PRMR Hospital Committee has been provided with details on the CollboRATE tool, but little information about the implementation and performance of the measure. For example, the measure specifications indicate that the tool has been developed for administration via paper handout, mail, electronic mail, computer or web interface, voice recorded telephone interviews, SMS text messages, and MyChart EHR integration. Yet, it is unclear which of these modes would be used for the survey as it informs the measure under consideration. The Preliminary Analysis notes that “the developer plans to administer the survey via a web interface provided by an approved survey vendor and will manually abstract the data for collection,” but it is unclear how this would be operationalized for use in a CMS program (i.e. would the developer contract with a single vendor, or would individual facilities be able to use existing survey vendors? Would there be an option for a facility to administer the survey tool directly?). Further, we request clarification on the patient population, i.e. which patients would be “eligible” as specified.

Of larger concern is the proliferation of outpatient surveys and the potential for overlap, redundancy and confusion.. The OQR already includes multiple patient-reported outcomes measures, including the OAS CAHPS survey and the Patient Understanding of Key Information Related to Surgery measure. The focus of the CollaboRATE measure appears to be extremely similar if not directly overlapping with questions in existing surveys. For example, the OAS CAHPS survey asks whether the doctor or anyone from the facility give you all the information you needed about your procedure, whether the doctors and nurses treated you with courtesy and respect, and whether they adequately explained the procedure. The Information Transfer measure asks whether the information provided by the facility considered the patient’s health needs and personal situation. While the purported aim of the CollaboRATE tool is to encourage shared decision-making specifically rather than quality of information provided or overall patient satisfaction, the distinction in outcomes of these various survey tools is unlikely to yield discretely useful results for patients or providers.

Due to the rapidly increasing number of patient-reported outcomes measures, particularly surveys related to experience, we suggest that CMS provide analysis of the trends of response rates in order to ensure low patient burden and collection of meaningful data.

As an Engaged Patient Partner with Healthcare Guidance, Measurement and Improvement efforts I see how this measure could be very beneficial to Patients, Carepartners and Clinicians alike. I have had good and not so good experiences with shared decision making discussions prior to surgeries. Having a survey for pre surgery with shared decision making preferenced attributes included could benefit all parties. 

I served on the WA State BREE Collaborative 'Surgical Patient Optimization: Glycemic Control and Anemia 2025 Report' Surgical-Optimization-FINAL-121625.pdf we had multiple evaluation discussions around what measures are important to gage best care before surgeries. From a patient point of view this measure is mutually beneficial though reading other comments the financial burden to facilities appears to be a concern. 

Shared decision making is important for best health outcomes and it is sad that $$ costs are too often more important than good old Clinician/Surgeon/Physician- Patient knowledge share and understanding. 

According to the measure description, the MUC2025-023: CollaboRATE Shared Decision-Making Tool for Ambulatory or Outpatient Surgery Patients (Surgical CollaboRATE OAS-PM) measure assesses facility level compliance with administration of the CollaboRATE Shared Decision-Making tool to patients undergoing outpatient or ambulatory surgery. To be compliant, facilities must offer 95% of patients the option to complete the CollaboRATE survey within one week of the shared decision-making conversation. Vizient has several operational concerns with this measure as it will impose additional operational and financial burden on hospitals, particularly because hospitals often must hire vendors or additional staff, or revise their information technology systems, to administer existing patient surveys. Further, providers may need additional guidance and support regarding how to effectively utilize information from the surveys. While Vizient appreciates efforts to increase shared decision-making, we are concerned with the additional burden associated with this measure, particularly as hospitals have numerous other reporting requirements and are already operating on thin margins.

In addition, Vizient is concerned with the agency’s interest in including this measure in the Hospital Outpatient Quality Program (OQR), as noted on the MUC List. Questions in the tool appear to be directed at whether the surgeon/proceduralist listened to the patient and helped the patient understand their health issues and choices. This type of communication during the preoperative process more commonly occurs in clinics, particularly for independent practitioners. Therefore, this measure is not best suited for the Hospital OQR and may be better suited to physician-oriented programs like the Merit-based Incentive Payment System (MIPS). 

Also, Vizient is concerned about introducing this new measure without considering alternative approaches to support shared decision-making or carefully reviewing the necessity of this measure in the context of other quality measures (e.g., Information Transfer PRO PM survey, OAS CAHPS survey) and overall burden on hospitals. 

In addition, while the measure previously received consensus-based entity endorsement in 2019, there is limited evidence to support expanding the measure to other quality programs. As provided in the materials associated with the measure, there is a lack of information regarding the measure’s validity and provider burden, particularly for those providers with limited resources. Since Vizient suggests adopting measures that are grounded in peer‑reviewed research to avoid excessive, unnecessary burden, given the need for additional evidence and analysis related to this measure, we caution broadening its use at this time. 

Dear Members of the 2025-2026 Pre-Rulemaking Measure Review (PRMR) Hospital Recommendation Committee:

The American Society of Clinical Oncology (ASCO), representing 50,000 oncology professionals, writes to express our support for the inclusion of the CollaboRATE Shared Decision-Making Tool (MUC 2025-023) in the CMS Hospital Outpatient (OQR) and Ambulatory Surgery Center (ASCQR) Quality Reporting Programs.

For the oncology patient, the transition of surgical services to the outpatient setting—including biopsies, port placements, and curative-intent resections (e.g., breast conservation, thyroidectomy)—requires a heightened level of shared decision-making (SDM). In oncology, a surgical decision often dictates the timing of toxic systemic therapies or radiation. Ensuring these decisions align with patient values is a clinical necessity, not an elective preference.

The landscape of surgical oncology is shifting rapidly. With elective procedures moving to the outpatient setting, many cancer patients now receive definitive surgical care in facilities where traditional "inpatient" support systems may be absent. As CMS continues to reduce the "Inpatient Only" list, oncology patients face increasingly complex choices in the ambulatory setting.

Current metrics in the ASCQR and OQR programs focus heavily on rare adverse complications (e.g., surgical site infections or readmissions). While vital, these measures fail to capture the quality of the diagnostic and therapeutic crossroads where oncology patients live. For a cancer patient, a "successful" surgery that ignores their preference for limb preservation or contradicts their palliative goals is a failure of care that current metrics cannot detect.

Research consistently shows that SDM is a driver of better outcomes and reduced costs. Specifically:

• Reduced Unnecessary Care: SDM is associated with lower medical expenditures, particularly when patients are empowered to choose less invasive options that align with their goals.
• Health Equity: Studies (e.g., Brown et al., 2023) indicate that SDM significantly reduces healthcare utilization gaps. High SDM scores were associated with an $871 reduction in annual medical expenditures per person, with the effect being most pronounced in racially and ethnically concordant relationships. In oncology, where racial disparities in treatment adherence and survival persist, these tools ensure every patient’s voice is heard.

• Reduced Regret: Cancer patients often face "preference-sensitive" decisions. Utilizing a validated tool ensures that the "effort" mentioned in the CollaboRATE questions translates to reduced patient regret and better psychological adjustment post-treatment.

   

While the Surgical CollaboRATE tool is an excellent, low-burden option, ASCO encourages ACS and CMS to allow for flexibility in the implementation of this measure. To ensure the broadest possible adoption and to minimize "survey fatigue," we recommend that the measure allow for the use of other validated SDM questionnaires that share the same intent and rigorous development as CollaboRATE.

Allowing for "equivalency flexibility" acknowledges that many high-performing oncology centers have already integrated specific validated tools into their Electronic Health Records (EHRs). A flexible framework would:

• Prevent Redundancy: Avoid forcing facilities to switch from one validated tool to another, which creates unnecessary administrative costs.
• Ensure Clinical Relevance: Allow specialties to use tools that may be more nuanced for specific oncology sub-types (e.g., breast cancer surgery option grids).

• Promote Innovation: Encourage the continued development of patient-reported outcome performance measures (PRO-PMs) across different clinical settings.

   

Appendix: Validated Alternatives and Alignment

ASCO recommends that ACS and CMS consider the following validated instruments and existing frameworks as acceptable equivalents to satisfy the requirements of MUC 2025-023:

• Tool: Shared Decision-Making Questionnaire 9-item version (SDM-Q-9)

  Focus: Process-oriented (9 items)

  Clinical Utility in Oncology: Measures the patient’s perception of the steps taken during the decision-making process; highly validated in oncology multidisciplinary teams.

• Tool: Decisional Conflict Scale (DCS)

  Focus: Uncertainty & Support

  Clinical Utility in Oncology: Identifies patients experiencing clinically significant conflict, which is a known predictor of lower post-operative activity and higher regret.

• Tool: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) (SDM Elements)

  Focus: Experience & Communication

  Clinical Utility in Oncology: Utilizes existing infrastructure within the "Preparation for Recovery" and "Communication" domains to reduce administrative burden.

ASCO recognizes that CMS has already mandated the use of the OAS CAHPS survey. We recommend that CMS explore harmony between MUC 2025-023 and the SDM-related elements already present within OAS CAHPS. For facilities already utilizing the OAS CAHPS electronic platform, adding the three CollaboRATE questions—or utilizing existing SDM-related CAHPS items—minimizes the "app fatigue" oncology patients experience when navigating multiple digital health platforms.

In medical oncology, the "best" treatment is the one the patient understands and chooses. We urge the Committee to recommend MUC 2025-023 for inclusion, with the added provision for facility flexibility to use other validated SDM instruments. This ensures that as oncology surgery moves to the outpatient setting, the patient’s voice remains a central metric of success.

Brown TT, Hurley VB, Rodriguez HP, et al. Shared Decision-making Lowers Medical Expenditures and the Effect Is Amplified in Racially-Ethnically Concordant Relationships. Med Care. 2023 Aug 1;61(8):528-535. doi: 10.1097/MLR.0000000000001881. Epub 2023 Jun 12. PMID: 37308806.

Sincerely,

The American Society of Clinical Oncology

The Iowa Hospital Association (IHA) appreciates CMS’s commitment to improving patient engagement and education through Shared Decision-Making (SDM) tools. While we recognize the value of SDM for individuals considering treatment or surgical procedures, we have significant concerns regarding the proposed assignment of this measure to hospitals and Ambulatory Surgery Centers (ASCs).

Responsibility for SDM Lies with Physicians, Not Facilities
The timing and application of SDM tools occur prior to surgery and fall under the physician’s accountability. Hospitals and ASCs often have no knowledge of when the SDM discussion occurred and may not interact with the patient until the day of the scheduled procedure. Therefore, this measure should be tied to a CMS 1500 claim by the surgeon and assessed as a physician-level measure, not a facility-level measure.

Misalignment with Patient Flow and Scope of Practice
Assigning this measure to hospitals and ASCs is inconsistent with their role in the care continuum. Future requirements for SDM discussions should remain within the provider’s domain, as they determine the need for and schedule the procedure.

Limited Availability of Standardized SDM Tools
Currently, only a small number of procedures have standardized SDM tools. CMS must clarify expectations for tracking and address how future SDM requirements will be implemented.

Administrative Burden and Risk of Delayed Care
Hospitals and ASCs often receive referrals from multiple counties and specialties, including dental. Requiring facilities to verify SDM completion and collect patient contact information for surveys would be burdensome and could delay care. Clinics and providers already have patient demographic information at the time of consultation and should be accountable for SDM discussions.

Additional Resource and Cost Burdens
Requiring hospitals and ASCs to mail or distribute paper surveys would create unnecessary administrative and financial burdens. As this proposal represents an unfunded mandate, if it is adopted in rulemaking and finalized, CMS should be obligated to reimburse hospitals for all associated costs, including printing and mailing.

IHA encourages CMS assign this measure to physicians and clinics rather than hospitals and ASCs. Additionally, CMS should provide clear guidance on expectations for SDM tracking, address the limited availability of standardized tools, and avoid imposing administrative requirements that could delay care or increase costs for facilities.

While Premier is generally supportive of patient-reported outcome measures (PROM), this measure is not a true PROM but a process measure. Rather than assessing the impact of shared-decision making, MUC2025-023 measures the administration of a shared-decision making tool, which neither creates incentives for providers to make the process meaningful, nor creates value for our healthcare system. Premier fears that this measure will result in a “check the box” activity that adds more burden to providers than value. CMS should continue to work with stakeholders to develop PROMs or shared-decision making measures that serve their purpose.   

The ASC Quality Collaboration - a non-profit organization representing more than 2,200 ambulatory surgery centers (ASCs) dedicated to advancing high quality, patient-centered care - would like to share the following thoughts regarding the CollaboRATE Shared Decision-Making Measure for Ambulatory or Outpatient Surgery Patients PRO-PM measure. 

We agree that shared decision-making is important. However, it is not clear how ASCs can use this measure, which determines the percentage of patients who were given a three-question survey on their perception of the visit with the clinician regarding the decision for surgery.

ASCs are often confused with clinics. However, Federal regulations dictate that ASCs exist completely autonomously from physician offices and function solely as a site for surgery. It is also important to know that Federal regulations limit ASC involvement in the care of the patient to the immediate preoperative, intraoperative and postoperative care on the day of service. Patients are not seen at the ASC for preoperative care prior to the day of surgery. Preoperative visits take place separately in the physician’s office or outpatient clinic, and the ASC, as a separate entity, is never a participant in those clinical discussions. The ASC becomes involved at the time that the physician’s office reaches out to the ASC to schedule the patient’s surgery or procedure, after the clinical encounter and after the decision for surgery has been made.

Because the ASC is not involved in the clinical encounter, it is not reasonable to hold the ASC accountable for the how much effort was made at that visit to help the patient understand their health issues, how much effort was made to listen to the things that mattered most to the patient about their health issues, and how much effort was made to include what mattered most to the patient in choosing what to do. The patient’s assessment of these items does not assess the quality of care given by the ASC on the day of surgery and could not be used to promote improvements in ASC care.

We believe this measure is most appropriately applied to the individual clinician who met with the patient to discuss their health issues and determine a course of action. A shared decision- making measure could certainly be developed for ASCs, but its focus would need to be on the decisions made at the facility itself on the day of surgery. This type of information would be meaningful and actionable in ASCs.

Support with Modification: Recommend alignment with CAHPS and safeguards to minimize survey burden and response bias

We have significant concerns regarding the cumulative patient survey burden associated with the Outpatient and Ambulatory Surgery (OAS) measures. Under current specifications, patients eligible for these measures may be subject to multiple, distinct patient-reported data collection efforts that cannot be consolidated due to measure-specific administration and timing requirements. These include, but are not limited to:​

• OAS CAHPS – post op survey​

• Information Transfer PRO-PM – post op survey​

• CollaboRATE (OAS-PM) - pre-op ​

• Total Hip and Total Knee PRO-PM surveys (when applicable) - pre and post op surveys

This list does not account for additional surveys associated with clinical registries (e.g., AJRR).

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​Patients undergoing outpatient or ambulatory surgical procedures already receive numerous communications, including appointment reminders, perioperative instructions, and post-operative follow-up messages. The requirement to administer multiple, separate surveys, often at overlapping time points and without the ability to combine outreach under current PRO-PM specifications, creates risk of survey fatigue, which may result in lower response rates, nonresponse bias, and reduced validity of patient-reported outcome and experience data.

We strongly urge CMS to consider measure design and implementation changes that would allow greater flexibility in survey administration, such as: 

• Allowing consolidation of patient-reported measures into a single, coordinated outreach when measures target the same episode of care; and/or
• Permitting alignment of survey timing and delivery methods across PRO-PMs and PREMs to minimize duplicative patient contact.

In addition, current measure requirements create a substantial operational burden for surgical service teams, who must identify eligible patients and manage compliance with multiple, non-aligned survey workflows across pre- and post-operative periods. Providing flexibility for consolidation and alignment would improve feasibility while maintaining the integrity and intent of patient-reported measurement.

C-TAC supports this measure as we advocate for patient-centered care, which can only occur when patients are fully engaged in making medical treatment decisions. Here, requiring shared decision making for outpatient or ambulatory surgery will help ensure that patients fully understand their surgical options and likely outcomes so as to make a fully informed decision. Informed consent is the cornerstone of ethical medical care and shared decision  making helps ensure that that can take place.

With regards to this MUC, there is concern within our organization related to Survey burden for patients who may be eligible for multiple surveys. Patients may be subject to overlapping patient-reported outcome data; for example post-operative OAS CAHPS, Info Transfer ProPM, THK PRO-PM and now this new proposed measure. 

We propose patient reported outcome measures and other survey types be re-reviewed and consolidated OR limiting eligibility for various surveys so that patients do not receive multiple surveys. We are concerned that increasing the burden of pre and post op surveys may result in reduced survey participation from the patient.

The financial and administrative burden for surveys administered to patients who have outpatient surgeries is cumbersome. We are currently required to administer the OAS CAHPS patient satisfaction survey to patients having outpatient surgery. A vendor is required for this, which costs us thousands of dollars annually. In 2027, we will be required to survey this same population of patients between days 2-7 postop for the Information Transfer PRO PM measure. This is a 9-item survey. The costs for having a vendor administer this is too much for our hospital (estimate was $40,000 + a year for this single survey/measure).  The administrative burden of this additional survey (Info Transfer PRO PM) is significant since we cannot afford a vendor for it. The proposed CollaborRATE survey will add an additional administrative burden. With healthcare reimbursements declining, we cannot add staff to internally administer and collect this data, and we cannot afford to have a vendor do it. 

Should the Surgical CollaboRATE OAS-PM survey be administered by the surgeon's offices rather than the Hospitals and Ambulatory Surgery Centers? The three questions asked are directed at whether the surgeon/proceduralist listened to the patient and helped the patient to understand their health issues and choices. The Hospital or Ambulatory Surgery Center is not responsible for that part of the preoperative process. These discussions between the doctor and patient happen in the clinics at preoperative visits. What benefit are the results of these questions going to have on the Hospital or Ambulatory Surgery Center? We can feed back the results to the surgeons/proceduralists, but often have no control of how they communicate this information in their clinics, particularly for independent practitioners. Understanding that Hospitals and Ambultory Surgery Centers will be scored on the percentage of patients offered the survey, not the survey results, but the burden of collecting this information is being put onto the Hospitals and Ambulatory Surgery Centers. The results are a reflection of preoperative communication happening before the patient arrives to the Hospital or Ambulatory Surgery Center for their procedure. This information is important for the surgeons/proceduralists to collect and take actions for improvment. 

Were patients involved in the development of the Surgical CollaboRATE OAS-PM measure? If so, were they made aware of the number of surveys that would be required for each oupatient procedure? Is this reasonable? For each procedure a patient would get this 3-item preoperative survey, the 9-item Information Transfer PRO PM survey in approximately the first week postoperatively, then the OAS CAHPS survey. Additionally, most physician's offices are sending out patient satisfaction surveys after office visits. So this same patient will likely receive surveys for their pre- and postoperative office visits. Will the number of surveys being sent for one procedure reduce the response rates, especially for the OAS CAHPS survey? Hospitals and Ambulatory Surgery Centers depend on OAS CAHPS patient survey feedback in order to make improvements to Hospial and Ambulatory Surgery Center processes. 

This measure would have numerous logistical challenges, as not all providers have integrated EHRs, not all patients are tech savvy for electronic versions, and tracking US mail, and scanning paper forms is not reliable and adds burden.  This burden is placed on the facility performing the procedure, and not on the provider bringing the patient to the facility.  Collection of patient reported outcomes has been very challenging with a total joint population, I can't imagine the burden for the entire OP surgery population. 

The American Occupational Therapy Association (AOTA) supports the intention of the CollaboRATE OAS-PM measure. Shared decision-making is vital to ensuring patients feel heard and can significantly influence their satisfaction with outpatient procedures. We believe that standardizing the process of shared decision-making can drive meaningful improvement, enhance patient satisfaction, strengthen care coordination, and provide accountability for providers.

Additionally, the use of a brief three-question survey helps balance the burden of integrating a new measure into existing care processes. However, given that the tool has undergone testing with a limited sample size, we encourage CMS to closely monitor the outcomes associated with this measure and continue seeking input from providers to ensure it achieves the intended impact.