Part 1: Measuring quality of performance: Where is it headed, and who is making the decisions?

The field of players, their initiatives, and the developments that could affect you

President and CEO, National Quality Forum, Washington, DC

Senior Vice President for Performance Measures National Quality Forum Washington, DC

If the realm of performance appraisal sometimes seems a confusing patchwork of diverse programs, there is a good reason. Concerns about health care quality and costs, patient safety, access to care, and disparities in care have prompted numerous independent corrective efforts.^1-8 Public and private sector purchasers have initiated pay-for-performance programs; the Centers for Medicare & Medicaid Services (CMS), state governments, and others will be issuing public reports of performance information; accreditation, regulatory, and professional certification entities are engaging in quality oversight; and quality improvement organizations (QIOs), health care providers, practitioners, and others are independently conducting quality improvement activities.

There are many stakeholders in US health care, each with reasonable interests driving these efforts. What is lacking is a national infrastructure built on strategic goals that can make possible the standardized performance information needed for all of these efforts to succeed. This is a fundamental building block for creating a national health system that provides high-quality care that is affordable and accessible to all Americans. This article provides a brief overview of the efforts under way to establish a national infrastructure to support standardized quality measurement and reporting.

  Framework for national quality measurement and reporting

For nearly a decade, expert panels have called for the creation of a national infrastructure to enable standardized quality measurement and reporting.^9-11 The figure depicts the general mechanics of such an infrastructure, composed of the following elements:

• National priority and goal-setting capacity. We need national priorities and goals for quality improvement, to focus scarce resources on high-leverage areas that will yield the greatest returns in improving health and health care.

• Measure development and maintenance. Scientifically and technically sound measures will allow us to gauge progress in meeting national goals and to address other areas where there are performance gaps.

• Evaluation and endorsement of standardized measures. A portfolio of standardized measures will support the efforts of many stakeholders engaged in quality improvement, accountability, and surveillance. Standardized metrics allow for “apples to apples” comparisons and minimize the burden on providers.

• Measure selection and implementation. A coordinated approach involving both public and private sector stakeholders is needed to select measures used for accountability purposes, including public reporting, pay-for-performance, and quality accreditation and certification programs.

• Data aggregation and reporting. Performance measures draw on data from many sources, including medical records, billing and administrative data, registries, electronic health records, and patient and provider surveys. Processes for aggregating and auditing data from these disparate sources and for accessing and reporting performance information are needed.

  Who’s who on the quality landscape

In the last few years, much progress has been made in delineating the roles and responsibilities of various organizations on the quality landscape. Key players in this process include major measure developers, the National Quality Forum (NQF), and the quality alliances (Figure).

Major measure developers and target areas

There are many types of performance measures and, not surprisingly, many organizations involved in measure development: accrediting bodies, specialty and subspecialty societies, government organizations, proprietary organizations, and others.

Setting measures for institutions. Measures were developed early on for hospitals and health plans. CMS (formerly known as the Health Care Financing Administration) released comparative reports on hospital mortality in 1986. Around that same time, the Joint Commission (formerly the Joint Commission on Accreditation of Health Organizations) began field testing standardized performance measures with the intent of requiring accredited hospitals to submit data on these measures.¹³ Also, the Joint Commission and CMS have developed many of the measures currently reported on the Hospital Compare Web site (www.hospitalcompare.hhs.gov). Through the pioneering efforts of the National Committee for Quality Assurance (NCQA), a standardized measure set, known as the Healthcare Effectiveness Data and Information Set (HEDIS), has been in place for health plans for well over a decade. CMS requires health plans participating in the Medicare program to report on the HEDIS measures, as do many state Medicaid programs and private purchasers.¹⁴

Measures for individual practitioners and practices. The recent push toward public reporting and pay-for-performance at the physician level has led to the proliferation of measures for physician specialties. The Physician Consortium for Performance Improvement (PCPI), convened by the AMA in 1998, has worked closely with more than 100 specialty societies at various levels of measure-development rigor and expertise to develop a broad array of specialty-specific measures of physician quality. Many of the NCQA’s health plan–level measures have also been adapted for use at the practice level, and NCQA has developed various physician practice recognition programs.

Several specialty societies, such as the Society for Thoracic Surgeons and the American College of Cardiology, have rich histories of performance-measure development. Others are new to the field.

For nursing professionals, the American Nurses Association has led the way with development of the National Database of Nursing Quality Indicators.

Adding a consumer focus. Finally, the federal Agency for Healthcare Research and Quality (AHRQ) has made significant contributions to measure development. In particular, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of instruments developed by the AHRQ has brought the critical voice of the patient experience of care to the measurement landscape. Also, too little attention is paid to measures of patient engagement in decision making and preparedness to implement their treatment plans. Correcting this deficiency will become a priority for stakeholders.

Other activities. In recent years, measure development by proprietary entities has also proliferated, often with a specialized focus on measurement and surveillance systems using available administrative and claims data. The AHRQ has also established a National Quality Measures Clearinghouse to assist users in identifying appropriate measures.

Evaluating and endorsing measures: the National Quality Forum

The National Quality Forum (NQF) is a private, not-for-profit membership organization with about 350 members representing every sector of the health care system: consumer organizations, public and private purchasers, physicians, nurses, hospitals, and other health care providers, accrediting and certifying bodies, supporting industries, and health care research and quality improvement organizations. Founded in 1999 by private and public leaders, NQF is a private-sector, standard-setting authority recognized under the National Technology Transfer and Advancement Act. In this role, NQF serves as a neutral evaluator of performance measures developed by others. NQF does not develop performance measures.

NQF endorsement, which involves rigorous, evidence-based review and a formal consensus development process, has become the “gold standard” for health care performance measures. To date, the NQF-endorsed consensus standards include more than 300 measures, preferred practices, and reporting guidelines spanning a wide range of settings and types of practitioners. The portfolio of NQF-endorsed standards is an important toolbox for providers and clinicians when selecting measures for quality improvement purposes, and for purchasers, accrediting and certifying bodies and others when selecting measures for accountability purposes.

In 2007, NQF significantly changed its mission, governance and committee structures, and standard-setting process to strengthen its role as the national coordinating and standard-setting center for performance measures. While continuing the important work of endorsing measures and best practices to promote patient safety and quality improvement, NQF is now working in partnership with other key stakeholders to develop a national strategy for performance improvement that will focus attention on “high leverage” areas most likely to yield the greatest gains for the US health care system.

Quality alliances

The last 5 years have seen the establishment of two influential national public-private collaborations: the Hospital Quality Alliance (HQA; 2002) and the AQA (formerly known as the Ambulatory Care Quality Alliance; 2004). The HQA focuses on hospital-level measures and the AQA on physician-level measures across all settings. Both quality alliances involve a broad range of stakeholders, including providers and practitioners, consumers, employers, health plans, and government agencies.

The HQA and the AQA have been instrumental in encouraging the widespread development and adoption of standardized measurement and reporting mechanisms. The major focus of the alliances is on implementation issues:

• Prioritizing measures for implementation.

• Facilitating development of effective processes for data collection, transmittal, aggregation, sharing, and reporting.

In addition to the HQA and the AQA, many smaller quality alliances exist, focusing on types of services (eg, Pharmacy Quality Alliance), patient populations (eg, Alliance for Pediatric Quality), and conditions and specialty areas (eg, Cancer Quality Alliance, Surgical Quality Alliance, Kidney Care Quality Alliance).

Recognizing the need for communication and coordination across the various quality alliances, the HQA and the AQA in 2006 formed a Quality Alliance Steering Committee (QASC). QASC has provided leadership for various pilot projects, many at the community or regional levels, aimed at pooling data from public and private sector health plans and other sources in order to (1) obtain a more complete picture of a provider or practitioner’s performance, and (2) look longitudinally at the quality, cost, and outcomes associated with episodes of care for patients with chronic conditions; these patients oftentimes receive care from multiple providers in many different settings. These community-based efforts are also intended to provide leadership for initiatives that can enhance population health and reduce disparities, and to build health system capacity to provide safe, effective care in a coordinated and efficient manner.

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11.  President’S Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Final Report. 1998. http://www.hcqualitycommission.gov. accessed oct 10, 2007.
12.  Health Care Financing administration. Medicare Hospital Mortality Information, 1986. Washington, DC: US Government printing office; 1987.
13.  Joint commission. Performance Measurement: Key Historical Milestones.http://www.jointcommission.org/NR/rdonlyres/CF91d166-C4C3-453A-8445-F26190F19107/0/SIWGVisionpaperwebversion.pdf. Accessed Oct 10, 2007.
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