• Performance Measures Criteria

    The primary purpose of performance measurement should be to identify opportunities to improve patient care. Performance measures address high-level patterns and outcomes of care comparing various dimensions of quality and cost across organizations and geographic areas.Performance measures may be used for improvement efforts, value-based payment programs, public reporting, patient decision-making, accountability, or allocating resources toward identified gaps in community and population health needs. The American Academy of Family Physicians (AAFP) works closely with other medical specialty societies, the National Quality Forum (NQF (www.qualityform.org), the Core Quality Measures Collaborative (CQMC (https://www.qualityforum.org/cqmc/)), the Centers for Medicare and Medicaid Services (CMS (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/index.html)), and others involved in performance measurement development, endorsement, harmonization, and/or implementation.

    Performance measures are not the same as but may overlap with quality measures which serve the purpose of accelerating internal clinical improvement.  

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

    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 which have the following attributes:

    • Focused on improving important processes and outcomes of care that matter to patients, are widely acceptable, and have a high impact on health, health care and/or costs;
    • Are based on best evidence and reflect variations in care consistent with appropriate professional judgment;
    • Allow exception/exclusions for informed patients' cultures, values, behavior, and preferences;
    • Are risk-adjusted, when appropriate, to account for factors such as demographics, severity, comorbidities, and social determinants of health;
    • Are within reasonable control of the entities or professionals being measured;
    • Are practical given variations of systems and resources available across practice settings;
    • Consider quality and cost when evaluating appropriateness;
    • Take into account the burden of data collection of multiple;
    • Provide transparency for methodology used;
    • Are updated regularly or when new evidence is developed; and
    • Are harmonized across all payers.

    The AAFP participates in the review, 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 NQF, CQMC, CMS, and others as appropriate.  

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


    Evidence-Based. The measure should be grounded in science, 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 clinical outcomes or 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 performance and/or a disparity in care across population groups should be demonstrated. The gap or disparity should be amenable to substantial improvement by means of feasible interventions.

    Severity and prevalence. The severity of 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, and address a nathional health priority or  hold the potential for substantial impact on the health status, health outcomes, and/or health care experience of individual patients or populations.

    Relevant. The measure should be important to physicians and their patients, should be kept up-to-date to reflect current knowledge and science 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. For composite measures, the components must be rationally related and weighted, and the composite must provide added value over the individual component measures, avoid all-or-none scoring, and not create undue burden.  

    Scientific Acceptability

    Reliability. The measure should be clearly defined, reproducible, and consistent across different practice settings.

    Validity. The measure is consistent with high quality evidence of efficacy and effectiveness, and accurately represents the concept of interest. There is face validity, indicated by obvious appropriateness or agreement by experts. The measure also has construct validity, depicting 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 measure should demonstrate the translation of best evidence of effectiveness into practice. The measure should be tested and validated at the level of care in which it is applied.  

    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/physician that is being assessed.

    Transparency. The measure can be esily and consistently interpreted by those using the information.

    Risk adjusted. The measure should be risk adjusted, if possible and appropriate, to account for factors beyond a physician's or health system's control, such as differences in practice settings, patient preferences, co-morbid conditions, cultural factors, and social determinants of health.

    Risk adjustment must not mask disparities in quality or equity of care resulting from implicit or explicit bias due to race, ethnicity, socioeconomic status or gender. 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 cost burden on those collecting the data and implementing improvements. Any costs 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.

    Reasonable time and effort. Data collection and reporting should not impose undue burden of time and effort. Data for measures should be routinely generated during care delivery and readily available, preferably in electronic health records or other electronic sources. Data collection strategy must:  

    • Maintain patient confidentiality;
    • Limit the number of required measures;
    • Allow realistic time frames for data collection;
    • To the extent possible, maintain consistency of measures and specifications over a period long enough to achieve improvement;
    • Include instructive materials;

    Harmonization. If similar or competing measures exist, measures should be compared to address hamonization and selection of the best measure, unless multiple mesures are justified.

    (1998) (2020 COD)