Uses of Quality Measures

Quality measures are used for three general purposes:

• Quality improvement
• Accountability
• Research

When measures are used for more than one purpose, the appropriate use for each purpose should be verified. NQMC's Advanced Search feature can be employed to identify measures for specific purposes by limiting the search based on the values in the Current Use field.

Quality Improvement

Quality measures can be used for both quality improvement within an institution or system of care (internal quality improvement) or across institutions or systems of care (external quality improvement). The Advanced Search feature allows selection of the values "Internal quality improvement" and "External oversight" in the Current Use field option to identify measures used for these purposes.

Using measures for internal quality improvement involves three basic steps: 1) identifying problems or opportunities for improvement; 2) selecting appropriate measures of these areas; and 3) obtaining a baseline assessment of current practices, and then re-measuring to assess the effect of improvement efforts on measure performance. Baseline quality measure results can be used to better understand a quality problem, provide motivation for change, and establish a basis for comparison across institutional units or over time. Baseline results also enable prioritization of areas for quality improvement.

Quality measures may be used for external quality improvement in programs operated by state, regional, or national entities or organizations, accreditation and quality improvement organizations, or professional organizations. The usual audiences for results of external quality improvement are the participating institutions or providers of care within the institutions. External agencies (e.g. state health departments, state or regional Quality Improvement Organizations [QIO's],) frequently collect the performance measurement data, verify their accuracy, and report quality performance results among providers of care in a format that allows for their direct comparison. External agencies may also make "benchmark" results available that can then be used to encourage performance at the best achievable level.

Accountability

Uses of quality measures for the purpose of accountability include purchaser and/or consumer decision making, variation in payment in relation to the level of performance and/or certification of professionals or organizations. Although employing quality measures for accountability may be quite similar to their use for external quality improvement, and the same set of organizations may conduct measurement for both purposes, the requirements for validity and reliability are higher when using measures for accountability. Greater validity and reliability demand that each provider collects data in the exact same way through standardized and detailed specifications. This ensures that comparisons are fair and/or that predefined measure performance has been achieved.

The usual audiences for accountability data are entities other than those that provide care, such as purchasers of health care, payers, regulators, boards and accrediting organizations, or patients. Their primary interest is in using accountability data to guide the selection of providers, set financial rewards to providers for performance, or certify that providers maintain required standards. They use results to compare provider groups, select providers based on performance levels in priority areas of clinical practice and/or consumer service, or establish and provide financial rewards. Some providers supply report cards or Web sites displaying clinical performance measurements so that consumers can make choices based on quality.

Consumer Decision Making

A number of public and private entities implemented tools designed to assist health care purchasers and/or consumers select higher quality or more efficient care. For example, the Centers for Medicare & Medicaid Services (CMS) operate the Hospital Compare Web site, which provides voluntarily reported hospital performance data to the public. Consumers can select local hospitals and view comparisons of hospital performance based on a defined set of measures. This information is intended to allow consumers to make more informed decisions about where to seek care, and may also be used by purchasers to inform decisions about which hospitals to include in provider networks or tiers. The Current Use field option of the Advanced Search function in NQMC includes the value "Decision-making by consumers about health plan/provider choice," as well as several similar values.

Performance-based Payment

In recent years, many public and private payers have implemented programs that adjust payments to providers or institutions based on the submission of performance data (pay-for-reporting) or on measured performance (pay-for-performance, or “P4P”). In their simplest form, P4P programs award bonus payments to providers in addition to scheduled fees if those providers meet defined performance benchmarks. These benchmarks may be relative (e.g., providers ranked in the top third of performance receive the bonus payment) or absolute (e.g., all providers achieving an objective minimum standard receive the bonus payment). Payers implement pay-for-reporting and P4P programs to create a direct financial incentive for providers to measure and improve performance. Both of these values appear in the Current Use field option of the Advanced Search function in NQMC.

Certification of Professionals or Organizations

Performance measures are increasingly incorporated into certification programs across a variety of health care professions and organizations. For example, through the American Board of Medical Specialties (ABMS) Maintenance of Certification process, board-certified physicians in 24 medical specialties participate in continuous professional development, earning ABMS Maintenance of Certification® (ABMS MOC®). Through Part IV of MOC, Practice Performance Assessment, physicians are evaluated in their clinical practice according to their use of specialty-specific measures of patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up measurements. Measures used for the purpose of professional certification can be identified in the Advanced Search function in NQMC by limiting the search to the "Professional certification" value in the Current Use field option.

Similarly, certification programs for provider organizations are becoming increasingly prevalent, such as the Diabetes Recognition Program offered by the National Committee for Quality Assurance (NCQA) and American Diabetes Association (ADA). Individual providers or multi-clinician practices can submit standardized data on ten diabetes-related performance measures, and if they maintain a composite score above the minimum threshold, they receive "Recognition," which may be used by purchasers and payers as the basis for bonus payments, placement in preferred tiers, or other benefits.

Research

The primary use of quality measures in research is to develop or produce new knowledge about the health care system that is generalizable to a wide range of settings and valuable in setting health policy. Quality-of-care research is often conducted to evaluate programs and assess the effect of policy changes on health care quality. Research may also be carried out to assess the reliability and validity of quality measures. Compared with their use for other purposes, the application of quality measures for research purposes may require larger sample sizes, more detailed data collection, the merging of multiple sources of data, and more complex analyses. Performance measures used in research can be identified through the Advanced Search feature in NQMC by selecting the "Quality of care research" value in the Current Use field option.

Current Uses of Measures

As noted above, the current uses of each quality measure, as indicated by the submitting organization, are captured in the Current Use field of the measure summary and can be identified by employing the Advanced Search feature. NQMC divides the broader categories of measure uses (i.e., Quality Improvement, Accountability, and Research) into more detailed and specific categories. Refer to the NQMC Template of Measure Attributes for a complete list of Current Use values.