Quality measures are “tools that help us measure or quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems...”1 They may also be called performance measures. The American Academy of Family Physicians’ (AAFP) policy states the primary purpose of performance measurement should be to identify opportunities to improve patient care. View our full list of criteria of a performance measure.
Measures inform us about how the health care system is performing. Measures help identify weaknesses, prioritize opportunities, and can be used to identify what works and doesn’t work to drive improvement. Measures can also prevent the overuse, underuse, and misuse of health care services and can identify disparities in care delivery and outcomes. Measures are used for quality improvement, benchmarking, and accountability. 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.
The table below defines and provides examples of some common measure types.
|Structure||A measure that assesses infrastructure, characteristics, or features of a health care organization or clinician relevant to capacity to provide health care, such as equipment, personnel, or policies.||
|Process||A measure that focuses on steps that should be followed to provide good care. There should be a scientific basis for believing the process, when executed well, will increase the probability of a desired outcome.||
|Outcome (including intermediate outcome)||A measure that assesses the results of health care, such as clinical events, recovery, and health status. Outcomes can be negative or positive. An intermediate outcome is an indicator or result that leads to a longer-term outcome.||
|Patient-reported Outcomes - Performance Measures (PRO-PMs) and Experience of Care Measures||A special outcome measure of a patient’s health status, quality of life, health behavior, or experience of care using information that comes directly from the patient, family, or caregiver without interpretation by a clinician or anyone else.||
|Resource Use/Cost/Efficiency||Measures that assess the cost of care, resources used (people, supplies, etc.) to provide care, inappropriate use of resources, or efficiency of care delivered.||
|Composite||A measure that combines several individual measures to produce one result that gives a more complete picture of quality for a specific area or disease.||
Choose measures that:
The Collaborative is a public and private, multi-stakeholder effort working to define core measure sets for various specialties. With significant input from the AAFP, the Collaborative developed an Accountable Care Organizations and Patient Centered Medical Home/Primary Care Core Measure Set for primary care.
This effort exists to:
A measure has several parts, including:
Benchmarking is comparing one's processes and performance metrics to the best performance and practices in the industry. In health care, benchmarks may be set internally or obtained from clinical data registries, payers (such as the CMS MIPS quality benchmark and accreditors (such as the National Committee for Quality Assurance [NCQA] Healthcare Effectiveness Data and Information Set [HEDIS] measures for health plans). Benchmarks should be challenging, but achievable to motivate improvement.
The NQF measure evaluation criteria align with criteria established by the AAFP. These include:
Additionally, measures should be evaluated for:
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:
The organization that develops and is responsible for updating and maintaining a measure is called a measure steward.
The process of measure development is lengthy and expensive, and requires review of evidence, analysis of care gaps, feasibility assessment, determination of data sources, development of detailed specifications, and field testing.
The NQF is a nonprofit, nonpartisan, membership-based organization which brings together public and private-sector organizations to reach consensus on how to measure quality in health care. NQF does not develop measures, but instead reviews, endorses, and recommends use of measures for various programs. NQF endorsement is voluntary, but endorsed measures are favored for use in federal and private-sector programs because of the rigorous process followed for endorsement.
The NQF uses a Consensus Development Process (CDP) to evaluate and endorse measures. For each topic, expert committees are formed, comprised of patients, physicians, other health professionals, suppliers, subject matter experts, and payers. The committee evaluates measures submitted by developers, issues a draft report of findings, gathers member and public comment, and votes to reach a consensus on endorsement recommendations. Committee recommendations are sent to the Consensus Standards Approval Committee (CSAC) where a final endorsement decision is made.
The AAFP does not itself develop measures, but advises developers and stakeholders to ensure the voice of family medicine is heard. The AAFP nominates its members as representatives to external workgroups that develop and endorse measures and responds during measure comment periods. The AAFP is represented on the NQF Measures Application Partnerships (MAP), which makes recommendations to CMS regarding measures that should be adopted for use in various payment and recognition programs, such as MIPS, Alternative Payment Models (APMs), Medicaid, and others.
1. Centers for Medicare & Medicaid Services. Quality measures.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html. Accessed February 7, 2018.