Performance Measures Criteria

Physician level clinical performance measures may be used for local improvement efforts, public reporting, accountability, or pay for performance programs. The American Academy of Family Physicians (AAFP) participates in the Physician Consortium for Performance Improvement (PCPI) sponsored by the American Medical Association and works closely with other medical specialty societies, the National Quality Forum (NQF(, and the National Committee on Quality Assurance (NCQA(, all of which are involved in performance measurement development, endorsement, harmonization, or implementation.

The AAFP encourages the utilization of performance measures that are consistent with the criteria described below for evaluating and improving patient care.

Statement of Principles

The AAFP is committed to promoting quality, cost-effective health care. The AAFP supports health care quality improvement endeavors, including the development and application of performance measures (whether single or in aggregate) which have the following attributes:

  • Focused on improving important processes and outcomes of care in terms that matter to patients;
  • Responsive to informed patients’ cultures, values, and preferences;
  • Based on best evidence and reflect variations in care consistent with appropriate professional judgment;
  • Are practical given variations of systems and resources available across practice settings;
  • Do not separately evaluate cost of care from quality and appropriateness;
  • Take into account the burden of data collection, particularly in the aggregation of multiple measures;
  • Provide transparency for methodology used;
  • Assess patient well-being, satisfaction, access to care, disparities, and health status;
  • Are updated regularly or when new evidence is developed; and
  • Are harmonized across all payers.

The spirit in which performance measures are developed and applied should be one of continuous improvement. The primary purpose of performance measurement should be to identify opportunities to improve patient care. Some measures will have usefulness for accountability, public reporting, or pay for performance programs. Efficiency of care measures, associated with a specified level of quality of care, is increasingly being incorporated into performance measurement sets. The PCPI Position Statement, The Linkage of Quality of Care Assessment to Cost of Care Assessment, describes "efficiency of care" as the relationship of the cost of care associated with a specific level of performance measured with respect to the other five Institute of Medicine (IOM) aims of quality.

Only the most evidence-based, widely accepted, and important measures should be used for accountability, pay for performanc,e or other significant decisions. When comparisons are made, they should be risk-adjusted, consider differences in denominator populations and account for variations in patient preferences, values, access, and availability of services. The AAFP policy statement on pay for performance programs can be found at: AAFP Policies.

The value of the application of performance measures should also be assessed in the context of physician, practice, and health system burden, economic costs and savings, and impact on patient-oriented outcomes that matter.

The AAFP participates in the development, endorsement, and harmonization of performance measures by nominating family physicians to represent the membership on workgroups pertinent to family medicine. This work is accomplished primarily through the PCPI and the NQF. The PCPI has developed Physician Performance Measurement Sets which offer clinical performance tools to support physicians in their efforts to enhance quality of patient care. Using physicians and other stakeholders, the NQF convenes steering committees and technical advisory panels to review, update, harmonize, and endorse performance measures.

The following criteria shall be used by the AAFP to evaluate the need, quality and acceptability of a performance measure.


Grounded in science. The measure should be evidence-based, explicit, and reflect the degree of scientific certainty. The aim of the measure should be to improve outcomes that are meaningful to patients. When intermediate processes of care are assessed, the causal pathway to improved patient-oriented outcomes should be strong.

Substantial potential for improvement. A significant gap should exist between optimal and current clinical practice. The gap should be amenable to substantial improvement by means of feasible interventions.

Severity and prevalence. The condition and its prevalence in the population should be significant enough to justify targeting the condition for improvement.

Substantial impact. The measure should be patient-centered, hold the potential for substantial impact on the health status, health outcomes, and satisfaction of individual patients and be capable of maintaining and/or improving the health of a community or population of patients.

Relevant. The measure should be important to physicians and their patients and should be amenable to evaluation.

Improve value. Measures should have the potential to improve value of health services for patients, plans, and purchasers of health care.


Accurate and reliable. The measure should be clearly defined, reliable, and consistent across different practice settings.

Valid. The measure is scientifically valid and based on high quality evidence of efficacy and effectiveness. There is face validity, indicating obvious appropriateness or agreement by experts; and, construct validity, indicating a comprehensive picture of the care being provided. Comparisons should be statistically valid, risk-adjusted, and account for differences in denominator populations or patient settings. The translation of best evidence of effectiveness into practice should be demonstrated.

Precisely defined and specified. The measure specifications should include:

  • The rationale or intent of the measure;
  • A description of the performance measure population;
  • A well-defined denominator with explicit inclusion and exclusion criteria;
  • Defined sampling procedures, when applicable;
  • Defined data elements and data sources;
  • Instructions for collecting data for the measure; and
  • Data elements that can be verified by the practice/physicians that is being assessed.

Easily interpreted. The measure can be interpreted consistently by those using the information.

Risk adjusted. If the measure is intended for meaningful comparison with the performance of others, it should be risk adjusted, if possible and appropriate. Consideration should be given to variations given differences in practice settings, patient preferences, cultural and social factors, and appropriate physician-patient decision-making. While adjustment should consider characteristics that impact health outcomes among different populations, including those beyond a health system’s control, it is important to retain accountability for developing systems and processes that strive for continuous quality improvement.


Improvement attainable. The health outcome goal of the measure can be achieved, or an improvement can be accomplished, in the settings in which it is applied.

Reasonable cost. The measure should not impose an inappropriate financial burden on those collecting the data. The cost of collecting the data and affecting improvements should be justified by impact on patient-oriented outcomes. There should be alignment between the cost of data measurement and performance improvement and funds dedicated to these processes.

Feasible. The measure should be feasible for a physician to meet. For example,

  • Data for the measures are readily available;
  • Patient confidentiality must be maintained;
  • The number of required measures is reasonable;
  • Realistic time frames are allowed for data collection;
  • To the extent possible, measures and specifications should remain consistent over a period of time long enough to achieve improvement;
  • Instructive materials should accompany performance measures;
  • Consideration is given to variation given differences in practice settings, patient preferences, cultural and social factors, and appropriate physician-patient decision-making;
  • Performance improvement can be implemented and maintained with reasonable effort; and,
  • The measurement is current and cost-effective.

(1998) (2015 COD)