MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 1
Health System Improvement
Measuring Health Care Quality:
An Overview of Quality Measures
ISSUE BRIEF / MAY 2014
/ Evidence Generation
ISSUE BRIEF / MAY 2014 WWW.FAMILIESUSA.ORG
In this brief, we answer
» What are the types
of quality measures?
» How are quality
» Where do data on
health care quality
» How are quality
» What’s next in quality
For a glossary of key terms
in quality measurement,
see page 14.
Measuring the quality of health care
is important because it tells us how the
health system is performing and leads
to improved care.
But what are the different types of quality measures,
how are they developed, and how are they used?
This brief provides an overview of these issues.
What is quality measurement in
health care, and why is it important?
Quality measurement in health care is the process of
using data to evaluate the performance of health plans
and health care providers against recognized quality
Quality measures can take many forms, and these
measures evaluate care across the full range of health
care settings, from doctors’ offices to imaging facilities
to hospital systems.
Measuring the quality of health care is a necessary
step in the process of improving health care quality.
Too often, the quality of care received in the United
States is substandard: Patients receive the proper
diagnosis and care only about 55 percent of the time,1
and wide variations in health care quality, access,
and outcomes persist.2 Research consistently shows
that there is chronic underuse, overuse, and misuse
of services. Furthermore, the way health care is
delivered is often fragmented, overly complex, and
uncoordinated. These problems can lead to serious
harm or even death.
Quality measurement can be used to improve our
nation’s health care by: 1) preventing the overuse,
underuse, and misuse of health care services
and ensuring patient safety; 2) identifying what
works in health care—and what doesn’t—to drive
improvement; 3) holding health insurance plans
and health care providers accountable for providing
high-quality care; 4) measuring and addressing
disparities in how care is delivered and in health
outcomes; and 5) helping consumers make informed
choices about their care.In our fact sheet on quality measurement, Measuring Health
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.
Patients receive the proper
diagnosis and care only about
55 percent of the time
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 3
can give a complete picture of the quality of care that
is provided and received. Rather, each type of measure
addresses a key component of care.
A Structure Measures
Structure measures evaluate the infrastructure of health
care settings, such as hospitals or doctor offices, and
whether those health care settings are able to deliver
care. These measures include staffing of facilities and
the capabilities of these staff, the policy environment in
which care is delivered, and the availability of resources
within an institution.
What are the types of quality
Quality measures assess care across the full continuum
of health care delivery, from the level of individual
physicians all the way up to the level of health insurance
plans. Hundreds of different quality measures are used
in health care. These measures generally fall into four
broad categories: 1) structure, 2) process, 3) outcome,
and 4) patient experience.
We discuss each of these measures below. However,
it is important to note that no single type of measure
“ The right care for the
right person at the
right time, the first
— Carolyn Clancy, former Director of
the Agency for Healthcare Research
and Quality (AHRQ)
Table 1. Types of Quality Measures
TYPE DESCRIPTION EXAMPLE
Structure Assesses the characteristics of a care
setting, including facilities, personnel,
and/or policies related to care delivery.
Does an intensive care unit (ICU) have a
critical care specialist on staff at all times?
Process Determines if the services provided to patients
are consistent with routine clinical care.
Does a doctor ensure that his or her patients
receive recommended cancer screenings?
Outcome Evaluates patient health as a result of the care
What is the survival rate for patients who
experience a heart attack?
Provides feedback on patients’ experiences of
Do patients report that their provider explains
their treatment options in ways that are easy to
Note to the reader: Unless otherwise stated, we
use the term “provider” as a catchall to refer to
the individuals (e.g., nurse practitioners) and the
institutions (e.g., hospitals) that are responsible
for providing health care services.
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 4
the ability to perform certain functions does not capture
whether or not these functions actually occur, nor does
it capture whether those functions improve patient
In short, the fact that a health care provider or facility
meets the requirements of a structure measure may
not result in that provider delivering care that improves
patient health. For example, some forms of provider
accreditation and certification require providers to
use electronic health records. A provider could buy an
electronic health record system but continue to rely on
paper records and still meet this structural requirement.
� Examples of structural measures include: Does a
hospital have a hand hygiene protocol in place? Does
a physician’s office use computerized order entry for
Structure measures are often used by insurance
companies and regulators to determine whether a
provider has certain capacities needed to deliver high-
quality care, such as whether a hospital has a system in
place to order prescription drugs electronically. These
measures are also commonly used in the certification or
accreditation of health plans and providers.
Two key reasons for using structure measures are that
characteristics of health care settings can significantly
affect the quality of care, and care settings that meet
certain standards have an advantage when it comes to
providing high-quality care.3
Although structure measures provide essential
information about a provider’s capacity, it is important
to note the limitations of these measures. In particular,
structure measures provide just one piece of the full
picture of care. For example, the fact that a hospital has
• Structure measures are necessary
to ensure that all plans,
providers, and care settings
have the critical tools needed to
provide high-quality care.
• While structure measures provide
essential information about a
provider’s ability and/or capacity
to provide high-quality care, they
cannot measure the actual quality
of the care received or whether
the care improved patients’
• Structure measures should be
considered a key part of a suite
of quality measures, but they
should never be relied on as the
sole measure of quality.
Table 2. Entity Being Evaluated
ENTITY DESCRIPTION EXAMPLE
Health Plan Assesses the services provided by the
health plan and the overall performance of
providers in the plan’s network.
Does the health plan cover treatment of
alcoholism or other drug dependence?
Provider Assesses the quality of a provider’s facilities
and/or the overall quality of care provided.
Does the hospital provide services to treat
alcoholism or other drug dependence?
Assesses the quality of care provided by an
individual health care professional.
Did the physician tell the patient that treatment
is available for alcoholism or other drug
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 5
» Process measures may also not capture the
true quality of the care provided. For example, a
measure that looks at what percentage of patients
who smoke received smoking cessation advice
will yield the same results whether the advice
provided was a brief admonition to quit or a
conversation with the patient about barriers he or
she faces when trying to quit and the availability
of smoking cessation supports.
� Examples of process measures include: Are nurse
practitioners routinely examining the feet of diabetes
patients to check for wounds? Are physicians
prescribing the appropriate drugs to their diabetic
B Process Measures
Process measures are used to determine the extent
to which providers consistently give patients specific
services that are consistent with recommended
guidelines for care. These measures are generally linked
to procedures or treatments that are known to improve
health status or prevent future complications or health
In most cases, assessing whether a provider meets
the requirements of process measures is clear-cut: Did
patients receive recommended care or not?
Process measures are useful in that they give providers
clear, actionable feedback and a straightforward way to
improve their performance. However, overreliance on
process measures to track performance and administer
provider incentives can be problematic, for several
» Process measures are not available for many
key areas of care, such as whether the care
provided was appropriate, or whether a provider
coordinated treatment for patients with physical
and mental illnesses, for example.
» Process measures that do exist tend to focus on
preventive care and the management of chronic
conditions, which may distract from other important
quality areas that are more difficult to measure.
Areas where measuring quality is harder include
teamwork and organizational culture.
• Having well-designed process measures is critical and can mean the difference between providing
recommended care and just checking off a box.ii
• While process measures typically reflect professional standards of care, they do not always
consistently predict outcomes, and users should be aware of their limitations.iii Good process
measures should always be backed by evidence that can reliably link a process with improved
• Current process measures are broadly focused on the areas of prevention and chronic disease
• Process measures are lacking in key areas of care that can also contribute to outcomes, such as
care coordination and technology. Process measures that are developed in the future should focus
on these key areas.
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 6
» Measuring outcomes often requires detailed
information that is available only in medical
records, and this information is difficult and
expensive to obtain.
» Gathering enough data to provide useful
information about a particular outcome can also
be a challenge.
» Although social determinants of health (such
as access to safe housing, social support, and
economic opportunity) can have a profound
impact on health outcomes, there is little
agreement on whether or not providers can be
held accountable for the confounding effects of
» Differences in patient population can make
certain outcomes more difficult to achieve. For
example, ensuring that a certain percentage of
a provider’s diabetic patients have controlled
blood sugar levels may be more difficult for a
provider with a patient population that is sicker
or that has multiple chronic conditions.
�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?
C Outcome Measures
Outcome measures evaluate patients’ health
as a result of the care they have received. More
specifically, these measures look at the effects,
either intended or unintended, that care has had on
patients’ health, health status, and function. They
also assess whether or not the goals of care have
been accomplished. Outcome measures are where
the rubber meets the road: Patients are interested in
surviving illness and improving their health, not the
clinical processes that support these outcomes.
Outcome measures frequently include traditional
measures of survival (mortality), incidence of disease
(morbidity), and health-related quality of life issues. And
while these measures often incorporate patient-reported
information on how satisfied patients are with the
health care services they’ve received, these measures
do not assess the full extent of the patient experience
(as described on page 7).
Although outcome measures are important to patients
and providers, their usefulness is limited by the fact that
developing outcome measures that are truly meaningful
can be quite hard. Key challenges to developing
meaningful outcome measures include:
• Because outcome measures
reflect what is most important
to patients, it is especially
critical that they are developed
with patient needs, values, and
preferences in mind.
• When developing, evaluating,
and using outcome measures,
it is important to recognize
the potential impact of social
determinants of health, as well
as critical differences in patient
• Outcome measures can be
particularly useful for patients
when they are choosing providers
or health care services if the
measures come with relevant
information on cost.
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 7
Experts are increasingly advocating for the inclusion
of patient experience as a key measure of quality
as the movement to improve health care quality
continues to develop and evolve. This trend has been
aided, in part, by the fact that the National Quality
Strategy includes measures of patient experience as
a key element.9(For more information on the National
Quality Strategy, see “How the Affordable Care Act
Improves Health Care Quality” on page 8.)
� Examples of patient experience measures include:
How long did patients have to wait before being
seen? Did a physician give easy-to-understand
information to her patients that addressed their
health questions or concerns? Did someone from the
provider’s office follow up regarding the results of a
blood test, x-ray, or other lab work? 10
D Patient Experience Measures
Patient experience measures provide feedback on
patients’ experiences of their care, including the
interpersonal aspects of care. But these measures
assess many other aspects of care, ranging from the
clarity and accessibility of information that doctors
provide, to whether doctors tell patients about
test results, to how quickly patients are able to get
appointments for urgently needed care.
Research shows that positive patient experiences have
a well-documented relationship to clinical quality:
Patients with better care experiences are often more
engaged in their care, more committed to treatment
plans, and more receptive to medical advice.8
• Patient experience measures
should be developed with patient
input to ensure that they are
representative of their needs,
values, and preferences.
• These measures reveal critical
information about the extent
to which care is truly patient-
• Although these measures are
relatively new, experts are relying
more and more on them as a core
element of health care quality.
• Patient experience measures
provide a rigorous, validated
alternative to the subjective
reviews that are posted on a large
number of online review sites.iv
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 8
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
overarching policy that is designed to lead
federal, state, and local efforts to improve the
quality of care and align public and private
payers in their quality and safety efforts.
» Established a Center for Quality Improvement
and Patient Safety to conduct and support
research on best practices for improving how
health care is delivered.
» Established the Patient-Centered Outcomes
Research Institute (PCORI) to support the
generation of patient-centered evidence that can
be used in measure development.
» Created the Center for Medicare and Medicaid
Innovation (CMMI) to test new payment
and delivery models that include quality
measurement and improvement as a key design
» Established a mandatory physician quality
reporting program (beginning in 2015) and the
development of a physician compare website for
» Requires public reporting on the quality of
health insurance plans that are sold in the new
state health insurance marketplaces.
» Requires additional reporting of patient data
related to race, ethnicity, sex, and language,
and requires qualified health plans to implement
activities to reduce disparities (variations in
access to care and in health outcomes due
to factors such as race, ethnicity, gender, and
» Authorized numerous new payment and
delivery models, such as value-based physician
payment, accountable care organizations
(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 9
Often, professional societies, such as the American
Heart Association (AHA) or the American College of
Surgeons (ACS), and public agencies like AHRQ, will
be the first to identify a critical mass of evidence on a
particular treatment. These societies or agencies then
develop clinical guidelines that may end up becoming
standards of care for many diseases and conditions.
These guidelines can be a starting point for determining
where quality measurement is needed and for providing
the critical evidence needed to develop such measures.
In addition, some societies or agencies go a step
beyond creating clinical guidelines—they create the
How does evidence become
a quality measure?
The evidence base that is used to develop clinical
guidelines is vast. The process of translating this
evidence base into quality measures varies widely
according to the type of measure, as well as the entity
that is charged with developing the measure.
In general, the process of developing a quality measure
includes convening a set of stakeholders to evaluate
the evidence and define the parameters of a quality
measure. Steps in this process generally include:
» Convening a committee whose members have
expertise on the particular issue to be measured
» Evaluating the evidence base, including primary
research and clinical practice guidelines
How are quality measures
All quality measures begin with an evidence base. But
how does research become an evidence base and then
a validated quality measure that can be applied to
multiple providers and/or health insurance plans?
Sound quality measurement begins with clinical
research that links a particular process, structure, or
outcome with improved patient health or experience
of care. For example, research has found that
administering a beta blocker as soon as possible to a
patient who is experiencing a heart attack can reduce
the risk of death. This protocol, supported by sound
evidence, was later developed into a clinical practice
guideline. A clinical practice guideline is a diagnostic
or treatment process that a clinician should follow for a
certain type of patient, illness, or clinical circumstance.
Who develops the evidence base?
A range of different groups are involved in funding and
developing the evidence base that is used to create
clinical practice guidelines. These groups include public
agencies like the National Institutes of Health (NIH), the
Agency for Healthcare Research and Quality (AHRQ),
and the Patient-Centered Outcomes Research Institute
(PCORI). Private businesses, such as pharmaceutical
companies and medical device developers, as well
academic research institutes, foundations, and
advocacy organizations, are also involved in developing
THE PATH FROM
RESEARCH TO FINALIZED
standard of care
finalized quality measure
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 10
» Reaching consensus on the best measurement
approach by considering numerous criteria,
including what the proposed measure would
evaluate and how that is relevant to consumers,
the scientific soundness of the evidence base, the
feasibility of measurement, and how data will be
» Developing detailed specifications about what will
be measured and how
» Vetting the specifications with key interest groups,
such as professional societies or consumer groups
» Conducting rigorous testing to ensure that the
measure works as it was designed
» Obtaining final approval by the entity charged
with developing the measure
Who develops quality measures?
The entities that develop quality measures include:
» Government agencies, such as the Centers for
Medicare and Medicaid Services (CMS) and the
Agency for Health Care Research and Quality
» Private nonprofits, such as the Joint Commission
on Accreditation of Health Care Organizations
(JCAHO) and the National Committee for Quality
» For-profit companies, such as Healthgrades and
U.S. News and World Report
When public agencies and nonprofits develop quality
measures, they often provide opportunities for
comment on their measures and make the measure
specifications publicly available. On the other hand,
for-profit companies often do not have the same
level of transparency in their measure development
How do measures get endorsed?
After a quality measure is developed, it is often
endorsed by professional societies and/or consumer
groups. The endorsement process is a consensus-
based process that allows stakeholders to evaluate a
proposed measure. Usually, a nonprofit (such as the
National Quality Forum—NQF) or government agency
(such as AHRQ) convenes stakeholders to rigorously
review potential quality measures and endorse
those that meet pre-established standards. These
stakeholders include the following:
» health care professionals
» payers (such as insurance companies)
» health plans
Measures endorsed by organizations like NQF are
generally recognized as reflecting a thorough scientific
and evidence-based review.
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 11
Where do data on health care quality
Once an agency, nonprofit organization, or company has
developed a quality measure, data must be collected to
support that measure. These data come from a variety
of sources. Often, complex measures require data from
more than one source.
Some common sources of the data that are currently
used to track quality measures include:
» Administrative data: Administrative data include
health insurance claims that are used to bill
payers for health care services. This type of data
is often the easiest to obtain, because health
plans and providers already have a robust
infrastructure to collect and share these data.
However, administrative data are limited in the
types of measures they can support. For instance,
while claims data can capture which services
were provided to which patients, they cannot be
used to determine whether these services were
appropriate for the patients who received them.
» Disease registries: These are organized systems that
capture data on patients with a specific disease or
condition beyond what is available in administrative
claims data. Public health agencies, including the
Centers for Disease Control and Prevention (CDC),
often develop and house disease registries. This data
system can capture information from multiple data
sources, including administrative data, as well as birth
and death records and Census data.
» Medical records: The information that providers keep
in patients’ health records contains far more detail than
claims data, including information on medical histories
and current medical conditions. However, these data
can be difficult to obtain, for several reasons. For
example, providers may use paper records that require
chart review. Some providers have electronic health
records, but different providers often use different
record systems, which makes it difficult to gather and
synthesize data across providers.
» Qualitative data: Qualitative data, such as data from
patient surveys, focus groups, and interviews, or data
from “mystery shopper” programs, provide the level
of detail needed for reporting patient experience
measures. These data are generally collected through
patient surveys that are administered by mail, phone,
or email, and they provide feedback on many different
elements of the care patients receive.
Collecting data on quality measures is a key challenge.
In the past, most health plans and providers were
not required to track and report data that measure
quality. Now, busy providers are often responsible for
tracking different quality measures for different payers.
For example, a provider may have to track one set of
measures for a health plan, another set for CMS, and
a third set for an accreditation agency. Having to meet
different requirements can be burdensome for providers.
Making the process of collecting data on health care
quality less onerous for providers may require new tools
and technologies, as well as recognition of the time it
takes providers to meet reporting requirements.
• The United States does not
have a designated agency that
is responsible for defining
standards for the development
of quality measures or for
quality reporting. This has
led to burdensome submit
requirements for health plans
and providers, who must submit
quality data to numerous
agencies and organizations.
• Just as importantly, patients
often have trouble understanding
information on health care
quality that comes from so many
• Future efforts to improve the way
health care quality is measured
should focus on aligning quality
measures across the different
groups that have developed or
endorsed them, as well as on
creating a single federal agency
with the authority to regulate
the process of developing
quality measures and the
way information on quality is
disseminated to consumers.
MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 12
The Promise of Electronic Medical
Records for Measuring Quality
The expanding use of electronic medical records has
the potential to transform the way that data on quality
are collected, assessed, and reported by making
information about health care and health outcomes
more accurate, timely, useful, and accessible.vi
How are quality measures used?
Currently, the most common uses of quality
measurements include public reporting, provider
incentive programs, and accreditation and/or
certification of providers and health plans.
» Public reporting: Providers and health plans, both
public and private, are increasingly making quality
measurement data available to the public to increase
provider accountability and promote informed
For example, the Centers for Medicare and Medicaid
Services (CMS) provides robust quality performance
data for hospitals in the Medicare program on its
Hospital Compare website. CMS also reports quality
data for the Medicare program on nursing homes,
home health agencies, and Medicare Advantage
plans, among others.12 Increasingly, private plans
are also publicity reporting provider performance
on quality measures, often combined with price and
» Provider incentive programs: Quality measures
are frequently used to direct financial rewards or
penalties to providers based on their performance.
For example, rather than paying providers for
the volume of care they deliver or the number of
patients they care for, payers can link all or part of a
payment to the quality of care that is delivered.
New models of care delivery, including accountable
care organizations (ACOs) and patient-centered
medical homes (PCMHs), use quality measurement
as a critical method of …
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