Quality measures in health care: Metrics and best practices
Get a handle on quality and performance measures to meet your metrics and improve patient outcomes.
Quality and performance measures take many forms and have implications for the health of your community and, often, your compensation. There’s a lot that goes into making, applying and meeting these measures. Knowing the basics and having strategies for implementation will give you a big step up.
What are quality measures in health care?
Quality measures are tools that quantify and inform us how the health care system is performing. Quality measures help identify weaknesses, prioritize opportunities and can be used to identify what works and doesn’t work to drive improvement. Measures are used for quality improvement, benchmarking and accountability.
The primary purpose of quality measurement should be to identify opportunities to improve patient care. Measures can prevent the overuse, underuse and misuse of health care services and can identify disparities in care delivery and outcomes.
Quality measures are typically developed based on evidence generated through research and clinical practice, with most measures beginning as clinical guidelines. Developers of measures include:
- Public agencies (e.g., the CMS and the Agency for Healthcare Research and Quality [AHRQ])
- Private nonprofits (e.g., the National Committee for Quality Assurance [NCQA] and the Joint Commission)
- Professional medical associations
- Private groups
Measure development is a three- to eight-year process that often costs around $1 million per measure. Once developed, adoption and use of a measure can take another two to five years.
Clinical quality measures vs. performance measures
Quality measures and performance measures can sometimes be the same measure, but they have different internal and external uses:
- Quality measures are intended for use within a medical clinic or organization to drive quality improvement efforts and are not tied to payment incentives or penalties.
- Performance measures are intended for use with payers and are often tied to payment incentives and penalties.
Both measures are becoming increasingly important relative to payment as the U.S. health care system shifts away from traditional fee-for-service toward payment focused on the value of care.
CMS is a major developer of quality measures. The CMS measure inventory houses over 500 measures designed to meet demands for performance data, promote quality and improve decision-making.
Each CMS quality measure is defined by a handful of selected metrics, including:
- Numerator: The subset of patients in the denominator for whom a clinical action or service has been provided or for whom a particular outcome has been achieved (i.e., the number of people that actually received an action or service). The numerator is the upper part of a fraction used to calculate a rate. (Example: Women who received a mammogram to screen for breast cancer.)
- Denominator: The given population to which a measure applies (i.e., the number of people who should have received an action or service). The denominator is the lower part of a fraction used to calculate a rate. (Example: Women 52-74 years as of December 31 of the measurement year).
- Denominator exclusions: The terms exclusions and exceptions are often used interchangeably, although there are subtle differences. An exclusion is a condition that removes a defined group of patients from the denominator because the measure would not appropriately apply to them. Exceptions depend on clinical judgment and remove patients from both the numerator and denominator. Exceptions are due to medical reasons (e.g., patient is comatose), patient reasons (e.g., patient refuses) and system reasons (e.g., shortage of a vaccine). (Example: Women who had any of the following: bilateral mastectomy; unilateral mastectomy with a bilateral modifier (same claim); two unilateral mastectomies with service dates 14 days or more apart; history of bilateral mastectomy).
CMS is most interested in outcomes-based measurements, but there are several types of measurements, including:
Best practices to improve performance on payer measures
Most of the time, the measures payers include in their contracts with physicians dictate which measures a clinic focuses on. Therefore, it's important to understand all the measures that are included in your contracts with payers.
Strategies that can help you maximize your performance on measures and improve patient outcomes include:
- Thoroughly understand each measure, including its definition, numerator, denominator, and applicable exclusions.
- Assess your baseline performance to establish a clear starting point and identify areas for improvement.
- Differentiate between payer attribution and internal clinic attribution to ensure clarity on which patients are included in performance evaluations.
- Regularly review performance reports and updates from payers, when available, to monitor progress throughout the measurement period.
- Accurately document performance measure data in the designated fields within your electronic health record (EHR) system.
- Leverage internal data monitoring tools, if available, to identify care gaps in real time.
- Implement automated and proactive outreach to engage patients with outstanding care needs.
- Utilize team-based care models and care management programs to support follow-up and coordination for targeted patient populations.
- Conduct pre-visit planning to ensure all care gaps are addressed during patient encounters.
AAFP resources and advocacy
The AAFP does not develop measures, but advises developers and stakeholders to ensure the voice of family medicine is heard and develops tools that can help family physicians navigate measurements.
Quality measures resources
- Take back your time with administrative simplification tips for quality measures.
- Earn free CME that shows you how to leverage health information technology for measures and more.
- Read the best articles on quality from FPM journal.
Quality measures advocacy
AAFP member representatives serve on more than 40 external quality measures committees, including the:
- Partnership for Quality Measurement
- Core Quality Measures Collaborative
- American Board of Family Medicine
- Centers for Medicare and Medicaid Services
- National Quality Forum
Policies that guide AAFP federal advocacy for simple, primary care–centered policy measures are: