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Health System Improvement

Measuring Health Care Quality:

An Overview of Quality Measures
ISSUE
MEASURING BRIEF
HEALTH CARE / MAY
QUALITY: 2014 OF QUALITY MEASURES
AN OVERVIEW / Evidence Generation 1
 Measuring the quality of health care Measuring the quality of health care is a necessary In this brief, we answer
step in the process of improving health care quality. these questions:
is important because it tells us how the Too often, the quality of care received in the United
health system is performing and leads States is substandard: Patients receive the proper
»» What are the types
of quality measures?
diagnosis and care only about 55 percent of the time,1
to improved care.
and wide variations in health care quality, access, »» How are quality
But what are the different types of quality measures, and outcomes persist.2 Research consistently shows measures developed?
how are they developed, and how are they used? that there is chronic underuse, overuse, and misuse
This brief provides an overview of these issues. of services. Furthermore, the way health care is »» Where do data on
delivered is often fragmented, overly complex, and health care quality
What is quality measurement in uncoordinated. These problems can lead to serious come from?
health care, and why is it important? harm or even death. »» How are quality
Quality measurement in health care is the process of Quality measurement can be used to improve our measures used?
using data to evaluate the performance of health plans
and health care providers against recognized quality
nation’s health care by: 1) preventing the overuse, »» What’s next in quality
underuse, and misuse of health care services measurement?
standards. and ensuring patient safety; 2) identifying what
Quality measures can take many forms, and these works in health care—and what doesn’t—to drive
improvement; 3) holding health insurance plans For a glossary of key terms
measures evaluate care across the full range of health
and health care providers accountable for providing in quality measurement,
care settings, from doctors’ offices to imaging facilities
high-quality care; 4) measuring and addressing see page 14.
to hospital systems.
disparities in how care is delivered and in health
outcomes; and 5) helping consumers make informed
In our fact sheet on quality measurement, Measuring Health choices about their care.
Care Quality: An Introduction, we explain what quality
measurement in health care is and why it is important, and
we discuss the ways that quality measurement can improve
health care quality. 55% Patients receive the proper
diagnosis and care only about
55 percent of the time

ISSUE BRIEF / MAY 2014 WWW.FAMILIESUSA.ORG

 What are the types of quality can give a complete picture of the quality of care that
measures? is provided and received. Rather, each type of measure “The right care for the
Quality measures assess care across the full continuum
addresses a key component of care. right person at the
of health care delivery, from the level of individual A Structure Measures right time, the first
physicians all the way up to the level of health insurance
Structure measures evaluate the infrastructure of health
time.” i
plans. Hundreds of different quality measures are used — Carolyn Clancy, former Director of
care settings, such as hospitals or doctor offices, and
in health care. These measures generally fall into four the Agency for Healthcare Research
whether those health care settings are able to deliver and Quality (AHRQ)
broad categories: 1) structure, 2) process, 3) outcome,
care. These measures include staffing of facilities and
and 4) patient experience.
the capabilities of these staff, the policy environment in
We discuss each of these measures below. However, which care is delivered, and the availability of resources
it is important to note that no single type of measure within an institution.

Table 1. Types of Quality Measures

TYPE DESCRIPTION EXAMPLE

Structure Assesses the characteristics of a care Does an intensive care unit (ICU) have a
setting, including facilities, personnel, critical care specialist on staff at all times?
and/or policies related to care delivery.

Process Determines if the services provided to patients Does a doctor ensure that his or her patients
are consistent with routine clinical care. receive recommended cancer screenings?

Outcome Evaluates patient health as a result of the care What is the survival rate for patients who
received. experience a heart attack?

Note to the reader: Unless otherwise stated, we

use the term “provider” as a catchall to refer to
Patient Provides feedback on patients’ experiences of Do patients report that their provider explains
the individuals (e.g., nurse practitioners) and the
Experience care. their treatment options in ways that are easy to
institutions (e.g., hospitals) that are responsible
understand?
for providing health care services.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 3

 Table 2. Entity Being Evaluated Key Considerations
ENTITY DESCRIPTION EXAMPLE
• Structure measures are necessary
to ensure that all plans,
providers, and care settings
Health Plan Assesses the services provided by the Does the health plan cover treatment of
have the critical tools needed to
health plan and the overall performance of alcoholism or other drug dependence?
provide high-quality care.
providers in the plan’s network.
• While structure measures provide
Provider Assesses the quality of a provider’s facilities Does the hospital provide services to treat essential information about a
and/or the overall quality of care provided. alcoholism or other drug dependence? provider’s ability and/or capacity
to provide high-quality care, they
cannot measure the actual quality
Health Care Assesses the quality of care provided by an Did the physician tell the patient that treatment
of the care received or whether
Professional individual health care professional. is available for alcoholism or other drug
the care improved patients’
dependence?
health.

• Structure measures should be

Structure measures are often used by insurance the ability to perform certain functions does not capture considered a key part of a suite
companies and regulators to determine whether a whether or not these functions actually occur, nor does of quality measures, but they
should never be relied on as the
provider has certain capacities needed to deliver high- it capture whether those functions improve patient
sole measure of quality.
quality care, such as whether a hospital has a system in health.
place to order prescription drugs electronically. These
In short, the fact that a health care provider or facility
measures are also commonly used in the certification or
meets the requirements of a structure measure may
accreditation of health plans and providers.
not result in that provider delivering care that improves
Two key reasons for using structure measures are that patient health. For example, some forms of provider
characteristics of health care settings can significantly accreditation and certification require providers to
affect the quality of care, and care settings that meet use electronic health records. A provider could buy an
certain standards have an advantage when it comes to electronic health record system but continue to rely on
providing high-quality care.3 paper records and still meet this structural requirement.

Although structure measures provide essential

„ Examples of structural measures include: Does a
information about a provider’s capacity, it is important hospital have a hand hygiene protocol in place? Does
to note the limitations of these measures. In particular, a physician’s office use computerized order entry for
structure measures provide just one piece of the full prescriptions? 4
picture of care. For example, the fact that a hospital has

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 4

 B Process Measures »» Process measures may also not capture the
Process measures are used to determine the extent true quality of the care provided. For example, a
to which providers consistently give patients specific measure that looks at what percentage of patients
services that are consistent with recommended who smoke received smoking cessation advice
guidelines for care. These measures are generally linked will yield the same results whether the advice
to procedures or treatments that are known to improve provided was a brief admonition to quit or a
health status or prevent future complications or health conversation with the patient about barriers he or
conditions.5 she faces when trying to quit and the availability
of smoking cessation supports.
In most cases, assessing whether a provider meets
the requirements of process measures is clear-cut: Did
patients receive recommended care or not? „ Examples of process measures include: Are nurse
practitioners routinely examining the feet of diabetes
Process measures are useful in that they give providers patients to check for wounds? Are physicians
clear, actionable feedback and a straightforward way to prescribing the appropriate drugs to their diabetic
patients? 6
improve their performance. However, overreliance on
process measures to track performance and administer
provider incentives can be problematic, for several
reasons.
Key Considerations
»» Process measures are not available for many • Having well-designed process measures is critical and can mean the difference between providing
key areas of care, such as whether the care recommended care and just checking off a box.ii
provided was appropriate, or whether a provider
• While process measures typically reflect professional standards of care, they do not always
coordinated treatment for patients with physical consistently predict outcomes, and users should be aware of their limitations.iii Good process
and mental illnesses, for example. measures should always be backed by evidence that can reliably link a process with improved
outcomes.
»» Process measures that do exist tend to focus on
• Current process measures are broadly focused on the areas of prevention and chronic disease
preventive care and the management of chronic management.
conditions, which may distract from other important
• Process measures are lacking in key areas of care that can also contribute to outcomes, such as
quality areas that are more difficult to measure. care coordination and technology. Process measures that are developed in the future should focus
Areas where measuring quality is harder include on these key areas.
teamwork and organizational culture.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 5

 C Outcome Measures »» Measuring outcomes often requires detailed
Outcome measures evaluate patients’ health information that is available only in medical Key Considerations
as a result of the care they have received. More records, and this information is difficult and • Because outcome measures
expensive to obtain. reflect what is most important
specifically, these measures look at the effects, to patients, it is especially
critical that they are developed
either intended or unintended, that care has had on »» Gathering enough data to provide useful with patient needs, values, and
patients’ health, health status, and function. They information about a particular outcome can also preferences in mind.
also assess whether or not the goals of care have be a challenge.
been accomplished. Outcome measures are where • When developing, evaluating,
and using outcome measures,
the rubber meets the road: Patients are interested in »» Although social determinants of health (such it is important to recognize
surviving illness and improving their health, not the as access to safe housing, social support, and the potential impact of social
clinical processes that support these outcomes. economic opportunity) can have a profound determinants of health, as well
as critical differences in patient
impact on health outcomes, there is little
populations.
Outcome measures frequently include traditional agreement on whether or not providers can be
measures of survival (mortality), incidence of disease held accountable for the confounding effects of • Outcome measures can be
(morbidity), and health-related quality of life issues. And particularly useful for patients
social determinants.7 when they are choosing providers
while these measures often incorporate patient-reported or health care services if the
information on how satisfied patients are with the »» Differences in patient population can make measures come with relevant
health care services they’ve received, these measures certain outcomes more difficult to achieve. For information on cost.

do not assess the full extent of the patient experience example, ensuring that a certain percentage of
(as described on page 7). a provider’s diabetic patients have controlled
blood sugar levels may be more difficult for a
Although outcome measures are important to patients provider with a patient population that is sicker
and providers, their usefulness is limited by the fact that or that has multiple chronic conditions.
developing outcome measures that are truly meaningful
can be quite hard. Key challenges to developing
meaningful outcome measures include: „Examples of outcome measures include: What
was the amputation rate for patients with diabetes?
What percentage of cancer patients went into
remission? What was the quality of pain relief for
patients who’d had knee surgery?

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 6

 D Patient Experience Measures Experts are increasingly advocating for the inclusion
Patient experience measures provide feedback on of patient experience as a key measure of quality Key Considerations
patients’ experiences of their care, including the as the movement to improve health care quality • Patient experience measures
continues to develop and evolve. This trend has been should be developed with patient
interpersonal aspects of care. But these measures input to ensure that they are
assess many other aspects of care, ranging from the aided, in part, by the fact that the National Quality representative of their needs,
clarity and accessibility of information that doctors Strategy includes measures of patient experience as values, and preferences.

provide, to whether doctors tell patients about a key element.9(For more information on the National • These measures reveal critical
test results, to how quickly patients are able to get Quality Strategy, see “How the Affordable Care Act information about the extent
Improves Health Care Quality” on page 8.) to which care is truly patient-
appointments for urgently needed care. centered.

Research shows that positive patient experiences have „ Examples of patient experience measures include:
• Although these measures are
a well-documented relationship to clinical quality: relatively new, experts are relying
How long did patients have to wait before being more and more on them as a core
Patients with better care experiences are often more seen? Did a physician give easy-to-understand element of health care quality.
engaged in their care, more committed to treatment information to her patients that addressed their
health questions or concerns? Did someone from the • Patient experience measures
plans, and more receptive to medical advice.8 provide a rigorous, validated
provider’s office follow up regarding the results of a
alternative to the subjective
blood test, x-ray, or other lab work? 10 reviews that are posted on a large
number of online review sites.iv

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 7

 How the Affordable Care Act Improves Health Care Quality
Beyond expanding health insurance and access to care, the Affordable Care Act includes numerous provisions
related to improving the quality of care in the United States. The health care law did the following:

»» Created a National Quality Strategy, the first »» Established a mandatory physician quality
overarching policy that is designed to lead reporting program (beginning in 2015) and the
federal, state, and local efforts to improve the development of a physician compare website for
quality of care and align public and private Medicare beneficiaries.
payers in their quality and safety efforts.
»» Requires public reporting on the quality of
»» Established a Center for Quality Improvement health insurance plans that are sold in the new
and Patient Safety to conduct and support state health insurance marketplaces.
research on best practices for improving how
health care is delivered.
»» Requires additional reporting of patient data
related to race, ethnicity, sex, and language,
»» Established the Patient-Centered Outcomes and requires qualified health plans to implement
Research Institute (PCORI) to support the activities to reduce disparities (variations in
generation of patient-centered evidence that can access to care and in health outcomes due
be used in measure development. to factors such as race, ethnicity, gender, and
socioeconomic status).
»» Created the Center for Medicare and Medicaid
Innovation (CMMI) to test new payment »» Authorized numerous new payment and
and delivery models that include quality delivery models, such as value-based physician
measurement and improvement as a key design payment, accountable care organizations
component. (ACOs), and patient-centered medical homes,
that all use quality as a key metric of success.v

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 8

 How are quality measures Often, professional societies, such as the American
THE PATH FROM
developed? Heart Association (AHA) or the American College of
RESEARCH TO FINALIZED
Surgeons (ACS), and public agencies like AHRQ, will
All quality measures begin with an evidence base. But QUALITY MEASURE
be the first to identify a critical mass of evidence on a
how does research become an evidence base and then
particular treatment. These societies or agencies then
a validated quality measure that can be applied to
develop clinical guidelines that may end up becoming
multiple providers and/or health insurance plans?
standards of care for many diseases and conditions.
research
Sound quality measurement begins with clinical These guidelines can be a starting point for determining
research that links a particular process, structure, or where quality measurement is needed and for providing
outcome with improved patient health or experience the critical evidence needed to develop such measures.
of care. For example, research has found that In addition, some societies or agencies go a step
evidence base
administering a beta blocker as soon as possible to a beyond creating clinical guidelines—they create the
patient who is experiencing a heart attack can reduce measurements themselves.
the risk of death. This protocol, supported by sound
evidence, was later developed into a clinical practice How does evidence become
clinical guidelines
guideline. A clinical practice guideline is a diagnostic a quality measure?
or treatment process that a clinician should follow for a The evidence base that is used to develop clinical
certain type of patient, illness, or clinical circumstance. guidelines is vast. The process of translating this
evidence base into quality measures varies widely standard of care
Who develops the evidence base? according to the type of measure, as well as the entity
A range of different groups are involved in funding and that is charged with developing the measure.
developing the evidence base that is used to create
clinical practice guidelines. These groups include public In general, the process of developing a quality measure
measure development
agencies like the National Institutes of Health (NIH), the includes convening a set of stakeholders to evaluate
Agency for Healthcare Research and Quality (AHRQ), the evidence and define the parameters of a quality
and the Patient-Centered Outcomes Research Institute measure. Steps in this process generally include:
(PCORI). Private businesses, such as pharmaceutical
»» Convening a committee whose members have finalized quality measure
companies and medical device developers, as well
expertise on the particular issue to be measured
academic research institutes, foundations, and
advocacy organizations, are also involved in developing »» Evaluating the evidence base, including primary
this evidence. research and clinical practice guidelines measure endorsement

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 9

 »» Reaching consensus on the best measurement When public agencies and nonprofits develop quality
approach by considering numerous criteria, measures, they often provide opportunities for
including what the proposed measure would comment on their measures and make the measure
evaluate and how that is relevant to consumers, specifications publicly available. On the other hand,
the scientific soundness of the evidence base, the for-profit companies often do not have the same
feasibility of measurement, and how data will be level of transparency in their measure development
collected processes.11

»» Developing detailed specifications about what will How do measures get endorsed?
be measured and how
After a quality measure is developed, it is often
»» Vetting the specifications with key interest groups, endorsed by professional societies and/or consumer
such as professional societies or consumer groups groups. The endorsement process is a consensus-
based process that allows stakeholders to evaluate a
»» Conducting rigorous testing to ensure that the
proposed measure. Usually, a nonprofit (such as the
measure works as it was designed
National Quality Forum—NQF) or government agency
»» Obtaining final approval by the entity charged (such as AHRQ) convenes stakeholders to rigorously
with developing the measure review potential quality measures and endorse
those that meet pre-established standards. These
Who develops quality measures?
stakeholders include the following:
The entities that develop quality measures include:
»» health care professionals
»» Government agencies, such as the Centers for
Medicare and Medicaid Services (CMS) and the
»» consumers
Agency for Health Care Research and Quality »» payers (such as insurance companies)
(AHRQ)
»» employers
»» Private nonprofits, such as the Joint Commission »» hospitals
on Accreditation of Health Care Organizations
(JCAHO) and the National Committee for Quality »» health plans
Assurance (NCQA)
Measures endorsed by organizations like NQF are
»» For-profit companies, such as Healthgrades and generally recognized as reflecting a thorough scientific
U.S. News and World Report and evidence-based review.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 10

 Where do data on health care quality »» Medical records: The information that providers keep
come from? in patients’ health records contains far more detail than Key Considerations
claims data, including information on medical histories • The United States does not
Once an agency, nonprofit organization, or company has have a designated agency that
and current medical conditions. However, these data
developed a quality measure, data must be collected to is responsible for defining
can be difficult to obtain, for several reasons. For standards for the development
support that measure. These data come from a variety
example, providers may use paper records that require of quality measures or for
of sources. Often, complex measures require data from quality reporting. This has
chart review. Some providers have electronic health
more than one source. led to burdensome submit
records, but different providers often use different requirements for health plans
Some common sources of the data that are currently record systems, which makes it difficult to gather and and providers, who must submit
used to track quality measures include: synthesize data across providers. quality data to numerous
agencies and organizations.
»» Administrative data: Administrative data include »» Qualitative data: Qualitative data, such as data from
• Just as importantly, patients
health insurance claims that are used to bill patient surveys, focus groups, and interviews, or data often have trouble understanding
payers for health care services. This type of data from “mystery shopper” programs, provide the level information on health care
of detail needed for reporting patient experience quality that comes from so many
is often the easiest to obtain, because health
sources.
plans and providers already have a robust measures. These data are generally collected through
infrastructure to collect and share these data. patient surveys that are administered by mail, phone, • Future efforts to improve the way
health care quality is measured
However, administrative data are limited in the or email, and they provide feedback on many different
should focus on aligning quality
types of measures they can support. For instance, elements of the care patients receive. measures across the different
while claims data can capture which services groups that have developed or
Collecting data on quality measures is a key challenge. endorsed them, as well as on
were provided to which patients, they cannot be In the past, most health plans and providers were creating a single federal agency
used to determine whether these services were not required to track and report data that measure with the authority to regulate
appropriate for the patients who received them. the process of developing
quality. Now, busy providers are often responsible for quality measures and the
»» Disease registries: These are organized systems that tracking different quality measures for different payers. way information on quality is
For example, a provider may have to track one set of disseminated to consumers.
capture data on patients with a specific disease or
condition beyond what is available in administrative measures for a health plan, another set for CMS, and
claims data. Public health agencies, including the a third set for an accreditation agency. Having to meet
different requirements can be burdensome for providers.
Centers for Disease Control and Prevention (CDC),
often develop and house disease registries. This data Making the process of collecting data on health care
system can capture information from multiple data quality less onerous for providers may require new tools
sources, including administrative data, as well as birth and technologies, as well as recognition of the time it
and death records and Census data. takes providers to meet reporting requirements.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 11

 »» Provider incentive programs: Quality measures
The Promise of Electronic Medical are frequently used to direct financial rewards or Key Considerations
Records for Measuring Quality penalties to providers based on their performance. • Administrative data such as
For example, rather than paying providers for health insurance claims are easy
The expanding use of electronic medical records has
and cheap to collect, but they
the potential to transform the way that data on quality the volume of care they deliver or the number of often cannot provide the level of
are collected, assessed, and reported by making patients they care for, payers can link all or part of a detail needed to assess health
information about health care and health outcomes payment to the quality of care that is delivered. outcomes.
more accurate, timely, useful, and accessible.vi • Medical records, particularly
New models of care delivery, including accountable electronic medical records, are a
care organizations (ACOs) and patient-centered key source of data for reporting
medical homes (PCMHs), use quality measurement outcome measures. However, a
How are quality measures used? lack of standardization across
as a critical method of allocating payments to record systems can make
Currently, the most common uses of quality participating providers. reporting difficult.
measurements include public reporting, provider
incentive programs, and accreditation and/or »» Accreditation and certification: Quality measures • While qualitative data such as
patient surveys are important for
certification of providers and health plans. frequently inform the standards that are used by measuring patient experience,
organizations such as the National Committee they can be time-consuming and
»» Public reporting: Providers and health plans, both for Quality Assurance (NCQA), URAC, and the expensive to collect, as well as
burdensome for providers. New
public and private, are increasingly making quality Joint Commission on Accreditation of Health Care methods for collecting data on
measurement data available to the public to increase Organizations (JCAHO) in their accreditation and/or patient experiences should be
provider accountability and promote informed certification of providers and plans. explored.
consumer choice. • As with all personal health
Accreditation and certification are often viewed as data, privacy is a critical issue.
For example, the Centers for Medicare and Medicaid important symbols of quality and can serve as a Though quality measures are not
Services (CMS) provides robust quality performance “seal of approval” for consumers.14 For example, intended to disclose information
on individual patients, ongoing
data for hospitals in the Medicare program on its the Affordable Care Act requires all qualified vigilance is needed to ensure
Hospital Compare website. CMS also reports quality health plans that are sold in the state health that quality measurement and
data for the Medicare program on nursing homes, insurance marketplaces and the federally facilitated reporting comply with existing
privacy laws.
home health agencies, and Medicare Advantage marketplace to be accredited.15
plans, among others.12 Increasingly, private plans
are also publicity reporting provider performance
on quality measures, often combined with price and
cost data.13

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 12

 What’s next in quality »» Making care safer by reducing the harm that is
measurement? sometimes caused during the delivery of care

Using quality measurement to improve health care is »» Promoting the most effective prevention and
a relatively new endeavor. While the U.S. health care treatment practices for the leading causes of
system has made great strides in developing and death
implementing quality measures over the past 15 years,
»» Promoting effective communication about and
much work remains.
coordination of care
One key step in this effort is the creation of the »» Ensuring that all individuals and families are
National Quality Strategy, the first comprehensive engaged as partners in their care
federal undertaking aimed at improving the quality of
care in this country. The Affordable Care Act required »» Working with communities to promote healthy
the secretary of Health and Human Services (HHS) to living
establish this national strategy for improving health care »» Making quality care more affordable for
that set priorities and that provided a plan for achieving individuals, families, employers, and governments
its goals: better care, affordable care, and healthier by developing and increasing the use of new
people and communities.16 health care delivery models17

Over the past three years, HHS has worked with Ongoing work to develop programs that operationalize
numerous stakeholders to develop a set of priorities for these principles will be needed to ensure that the
the National Quality strategy, which include: National Quality Strategy lives up to its promise.

The process of developing meaningful quality measures and putting

them into use is ongoing and will be refined over time. But as we collect
and evaluate more data on quality, we’ll be closer to ensuring that every
American gets the right care at the right time, the first time.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 13

 Glossary of Key Terms Morbidity: The incidence of disease, or how frequently a
in Quality Measurement condition or illness occurs in a given population.

Accreditation: Recognition that is granted to an Patient experience: The full range of patients’
institution (such as a health care provider or health interactions with the health care system, from scheduling
plan) by a professional association or non-governmental appointments to interactions with their providers to the
agency demonstrating that the institution meets pre- course of treatment, including whether these interactions
established standards. meet patient needs and health goals.

Certification: Recognition that is granted to an individual Patient-centered care: Health care that recognizes and
health care worker by a professional association or non- incorporates the distinct wishes and needs of individual
governmental agency demonstrating the individual’s patients, with an emphasis on patient values and
competency relative to a pre-determined set of criteria. preferences.
Clinical practice guideline: A standard of care based Quality health care: The right care for the right person at
on current, high-quality evidence that outlines the the right time, the first time.18
recommended course of care, including relevant options
and their outcomes, and that is designed to help Quality measure: A tool that is used to measure
providers make the best possible care decisions. performance against a recognized standard of care.

Disparities in health care: Variations in access to care Standard of care: Care that is delivered in accordance
and in health outcomes due to factors such as race, with clinical practice guidelines or other evidence-based
ethnicity, gender, and socioeconomic status. care protocols.

Evidence-based care: Health care that applies the best Value: The relationship of the clinical benefits of health
available research (evidence) when making decisions care to the cost of providing that care.
about a patient’s care.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 14

 Endnotes
1 Elizabeth McGlynn, Stephen Asch, John Adams, et al., “The Quality of Care Delivered to Adults in the United States,” The New England Sidebar Notes
Journal of Medicine 348, no. 26 (June 2003): 2,641, available online at http://www.nejm.org/doi/full/10.1056/NEJMsa022615. i
Transcript of remarks by Carolyn Clancy,
Measuring Health Care Quality (Washington:
2 Agency for Healthcare Research and Quality, 2012 National Health Care Quality Report (Rockville, MD: Department of Health and Human
Kaiser Family Foundation, 2008), available
Services, May 2013), available online at http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/2012nhqr.pdf. online at http://kff.org/archived-kaiseredu-
3 Paul Cleary and Margaret O’Kane, Evaluating the Quality of Health Care (Washington: Office of Behavioral and Social Sciences Research), org-tutorials/.
available online at http://www.esourceresearch.org/tabid/794/default.aspx. Mark Chassin, Jerod Loeb, Stephen
ii

4 Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse, Tutorials on Quality Measures: Selecting Structure Schmaltz, and Robert Wachter,
Measures for Clinical Quality Measurement, available online at http://www.qualitymeasures.ahrq.gov/tutorial/StructureMeasure.aspx, “Accountability Measures–Using
Measurement to Promote Quality
accessed on October 31, 2013.
Improvement,” The New England Journal
5 Jerry Cromwell, Michael Trisolini, Gregory Pope, Janet Mitchell, and Leslie Greenwald, Pay for Performance in Health Care: Methods and of Medicine 363, no. 7 (August2010),
Approaches (Research Triangle Park, NC: Research Triangle International, 2011), available online at http://www.rti.org/pubs/rtipress/ available online at http://www.nejm.org/doi/
mitchell/BK-0002-1103-Ch04.pdf. pdf/10.1056/NEJMsb1002320.

6 National Committee for Quality Assurance, The Essential Guide to Health Care Quality (Washington: NCQA), available online at http://www. Robert A. Berenson, Peter J. Pronovost, and
iii

ncqa.org/Portals/0/Publications/Resource%20Library/NCQA_Primer_web.pdf. Harlan M. Krumholz, Achieving the Potential

of Health Care Performance Measures
7 Robert A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, Achieving the Potential of Health Care Performance Measures (Washington: Urban Institute, 2013),
(Washington: Urban Institute, 2013), available online at http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406195. available online at http://www.rwjf.org/
8 Aligning Forces for Quality, Good for Health Good for Business: The Case for Measuring Patient Experience of Care (Washington: AFQ), content/dam/farm/reports/reports/2013/
rwjf406195.
available online at http://forces4quality.org/case-patient-experience.
iv
Aligning Forces for Quality, Good for Health
9 Department of Health and Human Services, 2012 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health
Good for Business: The Case for Measuring
Care (Washington: HHS, August 2012), available online at http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf. Patient Experience of Care (Washington:
10 Agency for Healthcare Research and Quality, Patient Experience Measures from the CAHPS Clinician and Group Surveys, Document no. AFQ), available online at http://
1309, updated May 2012, available online at https://cahps.ahrq.gov/surveys-guidance/cg/cgkit/1309_CG_Measures.pdf. forces4quality.org/case-patient-experience.

11 Robert A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, op. cit.

v
Robert Wood Johnson Foundation,
Provisions Related to Quality in the
12 Centers for Medicare and Medicaid Services (CMS), Hospital Compare website, available online at http://www.medicare.gov/ Affordable Care Act (Princeton, NJ: RWJF, May
hospitalcompare/search.html. 2010), available online at http://www.rwjf.
13 Robert A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, op. cit. org/content/dam/web-assets/2010/05/
provisions-related-to-quality-in-the-new-
14 National Committee for Quality Assurance, op. cit. health-reform-law.
15 Patient Protection and Affordable Care Act, Public Law 111-148 (March 23, 2010), as modified by the Health Care and Education Paul Cleary and Margaret O’Kane,
vi

Reconciliation Act of 2010, Public Law 111-152 (March 30, 2010), Title 1, Subtitle D, Section 1311. Evaluating the Quality of Health Care
16 Department of Health and Human Services, op. cit. (Washington: Office of Behavioral and Social
Sciences Research), available online at
17 Ibid. http://www.esourceresearch.org/tabid/794/
18 Transcript of remarks by Carolyn Clancy, Measuring Health Care Quality (Washington: Kaiser Family Foundation, 2008), available online at default.aspx, accessed on October 31, 2013.
http://kff.org/archived-kaiseredu-org-tutorials/.

MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 15

 A selected list of relevant publications to date:
Measuring Health Care Quality: An Introduction
(March 2014)
Principles for Consumer-Friendly Value-Based
Insurance Design (December 2013)
Key Differences between Reward/Penalty
Programs and Value-Based Insurance Design
(October 2013)

For a more current list, visit:

www.familiesusa.org/publications

Publication ID: 024HSI050114

This publication was written by:
Caitlin Morris, Senior Policy Analyst, Families USA
Kim Bailey, Director of Research, Families USA

The following Families USA staff contributed to the

preparation of this material (listed alphabetically): 1201 New York Avenue NW, Suite 1100
Evan Potler, Art Director Washington, DC 20005
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Carla Uriona, Director of Content Strategy info@familiesusa.org
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