Supplements and Featured Publications
The Quality Enterprise—What Is It, Where Is It Going, and How Will It Be Impacted by Healthcare Reform?
Volume 19
Issue 9 Suppl

Module 3: Measuring Quality in the Quality Enterprise


Continuous improvement is a core tenet of the quality enterprise, and measurement is necessary to gauge improvement. Therefore, there is a growing emphasis on measurement throughout the healthcare spectrum.

To meet the demands of the quality enterprise, the measurement field must continue to expand and evolve. Healthcare reform legislation will accelerate and shape the trajectory of that evolution. Along the way, significant barriers to proper measurement must be addressed.

Measuring Quality: Challenges and Limitations

In the reform era, measuring and gauging quality are essential but problematic. The major barriers are discussed below.

Inherent system complexity equals variations, lack of consensus, and lack of coordination

The US healthcare matrix is vast and extremely complex. Complex problems defy simple solutions. There are few national consensus measures. Existing quality-related definitions, approaches, mandates, and measures vary widely between stakeholders and from place to place, and often overlap and conflict. At present, the federal government (eg, CMS, Agency for Healthcare Research and Quality [AHRQ]), the Joint Commission, the NCQA, professional associations and societies (eg, AMA’s Physician Consortium for Performance Improvement), private corporations, and individual researchers have all developed measures used by health plans, hospitals, physician practices, and long-term care providers to compare performance.

Although some stakeholders are capable of measuring their own performance, they measure only against themselves, and information is seldom shared. Moreover, because quality standards are still evolving, many hospitals and health plans distrust the available data and have not committed to the systemwide measurement effort, although the PPACA will require sharing and measurement. To some extent, mistrust and reluctance to share might be understandable.

Quality Measurement: 10 Key Areas of Evolution

  1. Patient-level outcomes—better health • Linking health risks and outcomes • Avoiding complications (eg, hospital-acquired infections, medical errors, and medication errors) • Patient-reported functional status, health-related quality of life, and experience of care

  1. Processes of care—better care

• Technical effectiveness

• Coordination of care and transitions to care settings

• Alignment with patient preferences: shared decision making

  1. Cost and resource use (overuse, misuse, waste)

• Total cost of care across episodes of care

• Appropriateness

• Indirect cost: employee absence or reduced productivity

  1. Developing ways to aggregate complex information for measuring continuumwide performance (eg, composite metrics, efficiency data, deltas, dashboards)

  1. Measuring disparities throughout the continuum (eg, stratification, clinical and socioeconomic status risk profiles)

  1. Harmonizing measures across sites and providers

  1. Shared accountability across patient-focused episodes of care

  1. Meaningful use of HIT and clinical decision support

  1. Measures for patients with multiple chronic conditions

  1. Measuring and reporting performance systemwide

Under a VBP construct, reporting data and quality results can impact provider compensation.

Moving targets

In the dynamic and evolving reform environment, “best practices,” “quality,” and “quality improvement” are moving targets. Definitive quality solutions are therefore elusive.

Measuring at the population level

Patient-centered care is a cornerstone of reform and VBP. “After all,” said Ms James, “patients are on the receiving end of the care we deliver.” For overall reform to succeed, measurement must extend beyond individual patients to the patient population, the community, and beyond, to wider geographical regions and the entire nation.

Unaligned legacy system

The measures currently used in the quality enterprise were developed for other purposes, and are not readily adaptable for publicly reporting and rewarding quality performance. Although the legacy system does report some performance measures, those measures are not necessarily aligned with identified national priorities. The reverse is also true: some national priorities have been identified without corresponding performance measures.

Lack of/incomplete information and metrics; limits of HIT

Randomized controlled trials are the gold standard of evidence- based medicine; their results inform best practices for attaining optimum outcomes. However, the evidence base is lacking, incomplete, or mixed for many conditions, and especially for patients with multiple comorbid conditions. In those instances, discrete metrics are either unavailable or not yet feasible. For example, most trials exclude the frail elderly with multiple comorbidities, who often react to treatment differently from healthy young people or people with a single condition.

Even when the evidence base is sufficient, developing meaningful quality metrics is time-consuming, expensive, and difficult. Multiple, disparate data points must be aggregated and integrated. EHRs and other HIT should help resolve the problem. “The evolution of quality management pivots on automated records,” said Mr White. “That’s where many outcome measures can be found—not just outcomes for individual patients, but for an entire practice or population.”

The quality enterprise poses nuanced performance questions. To answer them, HIT must be configured to identify gaps in care, report outcomes in the same format from one record to the next, and help improve practice- or populationwide patient management. However, full HIT capability is not yet widely available or easily linked to other essential data, and current EMRs fall short. In 2000, RAND Health published quality measures specifically for frail elderly patients that took their multiple health issues into account. “A great measure set,” said Dr Weissberg. However, those measures are not readily extractable from claims data or EMRs. Dr Dobson commented, “I need—but current EMRs don’t provide— all the information I need to manage all of the patients I care for, whether or not they’re physically sitting in my office.”

On the other hand, HIT capability in general, and EMRs in particular, do not translate into better quality management or measurement unless properly used. For example, a physician might use EMRs to manage the care of patients who make appointments, but not use them to monitor the balance of the patient roster.

Finally, even if the necessary evidence base and HIT infrastructure were in place, no uniform standards currently exist for collecting, aggregating, and publicly reporting data. Proposed regulations have been issued under the PPACA to establish those standards.

Outcomes versus process: best medical practice versus best-practice delivery

Quality measurement involves not only the outcomes of care, but the process of care—how care is delivered. Process reaches beyond clinicians, physically administering treatment to patients. Process includes how patients enter, exit, and are routed through the system and its various care settings; process also includes patient preferences and shared decision making.

The current apparatus seems to be stimulating development of measures, but they may not be particularly meaningful for improving practice. Experts debate the relative utility of outcomes versus process measures, and the debate has implications for overall quality measurement. The panelists discussed the benefits of monitoring outcomes. Dr Weissberg noted that data about whether a patient with diabetes has taken a hemoglobin A1C test do not reveal whether the patient is in control according to accepted therapeutic targets. According to Mr White, employers want to know if their employees are healthier today than they were last month. Dr Dobson mentioned that a narrow focus on measuring process raises the risk that people will perform only to satisfy the measures, and lose touch with the results.

Having meaningful outcomes measures also raises the prospect that different paths could produce the same results, and provides the opportunity to justify care decisions based solely on cost. Future measurement systems should therefore be able to compare systems and identify the differences and similarities that yield positive outcomes.

The above debate, although relevant, relates only to clinical process and outcomes. Clearly, there is more to improving the quality of care as contemplated in the quality enterprise. The call to increase efficiency, and to reduce systemic waste and overuse of procedures, also involves process in a business operations sense. Said Ms O’Kane: “We’re sending people to see 7 different doctors and assigning a care manager to fill the gaps.” New processes are layered on top of old, and none of it is efficiently coordinated.

Proven quality improvement (QI) approaches from the business field, such as Six Sigma and Lean, may offer solutions for improving resource allocation and systems redesign. The medical establishment has generally resisted this idea, considering it an intrusion onto proprietary turf. Notable exceptions include the Mayo Clinic, Kaiser Permanente, and Intermountain Health Care (Intermountain). These organizations have redesigned their care processes via business models to reduce medical errors.

Short-term horizons

The measurement movement requires a long-term, national view of healthcare quality and cost. However, state governments historically focus on 1- or 2-year budget cycles, and are affected by politics. Insurers, according to Dr Dobson, “have side-stepped the long view. If you spend on a patient today, he or she may not be your patient tomorrow.”

Addressing the challenges

Public and private initiatives are under way to address the above challenges. The PPACA, by design, aims to accelerate these challenges. However, most measurement initiatives have been conducted by a select cluster of organizations, and as already noted, have involved their own populations.

On the private side, initiatives have typically been pursued by research-driven academic medical centers and large integrated delivery systems (IDSs) such as the Mayo Clinic, Intermountain, Kaiser Permanente, and Geisinger Health System. On the public side, Medicare initiatives relate only to Medicare beneficiaries. The results of these initiatives may prove too limited to extrapolate to the broad assemblage of healthcare organizations (HCOs).

Given the formidable challenges, Dr Salgo concluded: “We have an idea where we want to go on measurement, but insufficient concrete guidance on how to get there.”

The Need to Standardize and Harmonize Quality and Performance Measures

Harmonization: Vital to the Quality Enterprise

Quality measures are essential to nationwide reform. In order to align with the quality enterprise principle of full participation by all players and stakeholders, the measures must be standardized and harmonized across the national system and at every level in the spectrum, encompassing health plans and providers in all settings, including physicians, nurses, technicians, pharmacists, and their staff.

The Case for Standardizing and Harmonizing

  • If different payers use different quality measures, the administrative burden of measurement will add costs to the system and could generate conflicting assessments of quality and efficiency. This defeats the healthcare reform goal of eliminating duplication and unnecessary expense.
  • The healthcare value proposition supports the use of health information technology (HIT) capabilities for quality assessment. Standardized HIT protocols will promote efficient, systemwide data, making the entire data reservoir more robust, reliable, and accessible.
  • Standardized measures enable meaningful and transparent system-to-system, sector-to-sector, and region-to-region comparisons and evaluations, from which plans to improve can be devised and monitored. This applies on the supply side (healthcare organizations) and also on the demand side (so that patients can evaluate where to go for their care).

Lack of harmony in quality measures equates to mixed messages about best practices and desired outcomes. Allowing each constituent, or each state, to develop its own measures would perpetuate the existing fragmentation in the system.

ERISA and Medicare offer lessons on these points. ERISA promoted harmony: “ERISA enabled multi-state employers to avoid a tangle of different state standards,” said Mr White.

On the other hand, Medicaid, although well-intentioned, bred disharmony. Because Medicaid aims to accommodate differences in state patient populations, the law gives each state wide latitude to develop and administer its own program. “Medicaid induced chaos at the outset; we can’t repeat that mistake,” noted Dr Dobson.

Harmonizing measures also promote the shift toward patient-centered care and outcomes. “It will help us focus on results for the patient and what the patient wants,” said Mr White. “For example, is my hemoglobin A1C in control? Is my blood pressure in control?”

Harmonization is also important to employers. Having healthy, productive employees is not only in employers’ financial interest, but is also a point of unification and connection, because everyone agrees about its importance. In that regard, The National Business Coalition on Health is working with a state that captures biometric data. Those data identify people with prediabetes and people with undiagnosed hypertension. Armed with data, the state could gauge the current health status of certain population segments, and formulate goals to improve their status. Then, as purchasers with great leverage, they can reach out to their vendors and insist they do something to drive improvement, reaching all the way down to the medical home and the doctor level.

As for how to approach the challenge to harmonize standards, Dr Weissberg offered a credible, large-scale start. “Public sources now fund over 50% of healthcare in the United States. If all publicly funded programs, including Medicare, Medicaid, VA, DoD, and IHS, endorsed the same set of consensus measures and goals, healthcare in the United States would take a quantum leap to the better.”

Harmonization and PPACA-Mandated Exchanges

The Medicaid example is particularly relevant and instructive with respect to harmonizing measures, because of PPACA-mandated state exchanges. Although the Medicaid experience must be avoided, the final regulations governing the exchanges must nevertheless take into account the distinctive needs of each state and its patient population, and allow the flexibility to customize.

In that regard, Dr Dobson believes that the PPACA framework resembles ERISA rather than Medicaid. “By building on common, harmonized standards, we can have 50 exchanges that are sensitive to state differences.” Under the PPACA, in order to sell on the exchanges, qualified health plans must be accredited by an accrediting entity recognized by HHS based on local performance in: (1) clinical quality measures such as the Healthcare Effectiveness Data and Information Set (HEDIS); (2) patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems; and (3) quality assurance. Because the number of accreditors is limited and those accreditors work similarly, the process is less chaotic.

Is Harmonization Under Way?

Dr Weissberg believes that generally, harmonization is occurring “because we’re working off the same core set of standardized, vetted measures.” In addition, under the PPACA, the National Quality Forum has been engaged to analyze the universe of plans and providers and distill a harmonized consensus.

Dr Dobson noted “a significant movement” to establish standardized, harmonized quality measures across Medicare and other government programs. As examples, he cited CMS’ Advanced Primary Care Initiative, and the quality-related provisions of the Children’s Health Insurance Program Reauthorization Act of 2009.

Current Quality Measurement Initiatives

Overall, the number of hospital performance measurement and reporting initiatives has grown; examples include’s Hospital Compare; The Joint Commission’s Quality Check; and U.S. News & World Report’s Best Hospitals Rankings. Other initiatives, including initiatives in specialty areas, are gaining momentum. For example, in behavioral health, nearly 40 public and private initiatives are under way to establish quality measures relating to patients’ physical health and adherence to medication. In oncology, the American Society of Clinical Oncology and the National Comprehensive Cancer Network have collaborated to develop 7 evidence-based quality measures for breast and colorectal cancers.

Measure Development and Endorsement

Healthcare Reform and PPACA Impacts

  • NQF’s consensus development process (CDP)—intended to evaluate and endorse consensus standards, including performance measures. NQF convened the multi-stakeholder National Priorities Partnership (NPP). NPP’s mission included obtaining input from all healthcare industry stakeholders.
  • PPACA—directs HHS to seek multi-stakeholder input on use of quality measures for public programs.

Key Goals/Examples

  • Align with the national priorities and strategy for quality improvement—NPP’s mission entailed (1) setting national priorities and goals for performance improvement, and (2) endorsing national consensus standards for measuring and publicly reporting on performance.
  • Identify priority measure gaps to direct development resources toward high-leverage areas—NPP identified 20 high-impact Medicare conditions.
  • Continuously monitor the measure development pipeline to make mid-course corrections, as necessary.

Measurement Development and Healthcare Reform Legislation

  • AHRQ and CMS will conduct triennial assessment of gaps in quality measures (PPACA Section 3013).
  • $75 million authorized for quality measure development (PPACA Section 3013).
  • Expanded public reporting and new performance-based payment reform models (various PPACA provisions).
  • Measurement of HIT meaningful use (ARRA Health Information Technology for Economic and Clinical Health [HITECH] provisions).
  • Mandate and funding for child health performance measures (Children’s Health Insurance Program Reauthorization Act of 2009).
  • Under the PPACA’s hospital VBP model, clinical and patient satisfaction measures will be combined into 1 composite VBP score for each hospital.

Healthcare Reform Impacts on Developing Quality Measures

Although now in the spotlight, measure development and endorsement approaches, and efforts to harmonize them, have been progressing for more than 20 years, led by NCQA and NQF. As previously noted, healthcare reform in general, and the PPACA in particular, will impact measurement development and endorsement initiatives. The PPACA, in fact, contains many provisions relating to those topics.

Is PPACA premature?

Dr Salgo speculated that given the lack of standards and gaps in the evidence base, some might consider the PPACA premature. To skeptics, the legislation seeks “to pay for it all and harmonize it all without any data at all.”

According to Ms O’Kane, the legislation is neither premature nor bereft of data. She noted that NQF has already approved more than 700 performance measures, and experts are providing extensive input on others. Also, measures already exist for 118 million Americans covered by health plans.

Measurement and the transition to patient-centered healthcare

The notion of patient-centered healthcare has been growing in impact over the last several years. Patient-centered care is now influencing delivery systems and policy, and will eventually impact and shape measuring.

The patient is also a focus for purchasers, particularly employers. Mr White noted that “Employers must care about employees as patients, because human capital is their most valuable asset. Employers also have an internal incentive, if not a responsibility, to promote designs that motivate employees to stay healthy.” Preserving human capital is aligned with employers’ financial interests. Therefore, employers will “expect the provider world to get the measures right.”

The link between quality measures and high-deductible health plans

Despite the focus on patients, quality measures may, as a practical matter, be of little use to patients, in particular those with high-deductible health plans (HDHPs). HDHPs are grounded in the idea that consumers with a greater financial responsibility for their care will be more invested in seeking high-value, high-quality services, and thereby become engaged in the quality enterprise. In fact, HDHPs may adversely affect outcomes. Ms O’Kane explains: “Research shows that less than half the country has $1000 in the bank,” said Ms O’Kane. “If you require consumers to pay a $2000, $5000, or $10,000 deductible, they simply can’t afford to pay for their primary care or essential medicine.” This is particularly troublesome because primary care is the primary access point to the healthcare system and primary care is being re-emphasized in the current reform scheme.

Others argue that well-designed HDHPs have a legitimate role, leveraging high deductibles to educate and motivate employees about how to stay healthy and productive at work. Ms O’Kane brushes this notion aside: “Ultimately, if people can’t pay their deductibles, what they want becomes irrelevant and quality outcomes will be compromised.”


Overall, the quality component of the quality enterprise involves measuring what care is delivered and how it is delivered. However, quality measurement is a relatively new field, and in its current state is not up to the full breadth of the task. EMRs and other HIT have the potential to aggregate and process data in the ways needed to enable proper measurement; however, HIT must also evolve.

The discussion about measurement and the attendant challenges underscores another, overarching challenge to reform: imposing a new world view, and new approaches, on a change-resistant culture. Overcoming this challenge requires time and judicious management.

Ms O’Kane and Mr White acknowledge that the current measurement landscape is imperfect and that more and better measures are needed, but neither is discouraged. “That’s the point of this reform model,” said O’Kane. “We have to keep working to improve.” Said White: “The legislation puts stakes in the ground and lays out an agenda for improving measures. It recognizes where we are and allows us to go forward.” O’Kane juxtaposed the current imperfection to the alternative: “Medicine in the dark, where nobody knows how we’re doing.”

Dr Salgo ended the session with a larger question: “Where is this all going? Nobody in the system now thinks he or she is delivering poor care.” Responded O’Kane: “That’s right. They’re working in the dark; it takes quality measurement to turn the lights on.”Dennis White participated in the roundtable discussion; however, he has not reviewed this manuscript.

Author affiliations: Community Care of North Carolina, Raleigh, NC, Engelberg Center for Health Care Reform, Brookings Institution, Washington, DC, and University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC (LAD); Humana Inc, Louisville, KY (MGJ); National Committee for Quality Assurance, Washington, DC (MEO); Cardiothoracic Intensive Care Unit and Surgical Intensive Care Unit, Columbia University College of Physicians and Surgeons, New York, NY (PS); Kaiser Permanente, Oakland, CA (JW).

Funding source: This information contained in this publication was sponsored by GlaxoSmithKline (GSK). GSK reviewed the content of this publication for compliance with its own policies; GSK played no role in the selection or content of the material that appears here.

Author disclosures: Ms James reports employment, meeting/conference attendance, and stock ownership with Humana Inc. Dr Weissberg reports employment with Kaiser Permanente and board membership with Archimedes and Avivia Health. Dr Weissberg has also disclosed ownership of various stocks; information on file at the office of The American Journal of Managed Care, Plainsboro, New Jersey. Ms O’Kane, Dr Dobson, and Dr Salgo report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this supplement.REFERENCES

Carroll, RL; American Society for Healthcare Risk Management. Risk Management Handbook for Health Care Organizations (Student Edition). San Francisco, CA: Jossey-Bass; 2009.

Domann D. The Growing Emphasis on Quality Measurement under Health Care Reform. Medicaid Health Plans of America. Published November 5, 2010.

National Quality Forum (NQF), Guidance for Measure Harmonization: A Consensus Report. Washington, DC: NQF; 2010.

Standards and Certification. US Department of Health & Human Services, Office of the National Coordinator for Health Information Technology website. Accessed August 27, 2012.

Valuck T. Applying Measures to Improve Quality: Health Reform Implications for Performance Measurement, Public Reporting, and Payment Incentives. NAPH Fall Conference; November 9, 2010.

Voices of value-based purchasing: health care leaders reflect on 15 years of leadership. National Business Coalition on Health website. Accessed August 26, 2012.

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