Basics of Health Care Quality: The Metrics of Quality

Measuring What Matters

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The Different Dimensions of Health Care Quality

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Just curious, what exactly comes to your mind hearing the word health care "quality”?

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Hopefully, as a professional, whether your vantage point is through the lens of a policy stakeholder, hospital administrator, clinician, quality metrics data analyst, or a rheumatoid arthritis patient who is passionate about helping others who live with the same disease, we would all hold a common viewpoint.

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So what does that perspective look like?

In the February 24th Health Care Quality Insights article, “The Big ‘Picture’ of Health Care Quality in the U.S.”, I wrote about the practical side of health care quality. Specifically, the aspects which involve experiencing health care, or what we all hope to receive as a patient, participate as a health care worker, and what we have available to us as consumers.

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Numerous books have been written about health care quality.  Therefore, my goal in this article is to share just enough background and content to enable an individual working in any aspect of health care (including passionate patient advocates) to develop an appreciation for what the field of health care quality involves, and why it should matter to them.  This article focuses on the metrics of health care quality (otherwise known as quality measures). But first, a little historical context.

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Health Care Quality History 101

Three seminal events anchor the history of the health care quality field.  The first two are published reports. Notably, both are Institute of Medicine (IOM) national landmark reports centered on the state of health care quality in the United States. The first is To Err is Human: Building a Safer Health System (1999), and the second, Crossing the Quality Chasm: A New Health System for the 21st Century (2001).

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In brief, these reports unearthed the highly uneven quality of health care in the United States. They underscore that some places were shown to have world-class-level standards of quality, while, in stark contrast, standards of other locations rivaled currently-defined third world countries. Not surprisingly, in the vast majority of locales, the quality standards spanned the range between these two extremes.

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The two IOM reports offered a clarion call for major health care reform.  

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The third seminal event that undergirds the field of health care quality was the enactment of the Affordable Care Act of 2010 (ACA).

This pioneering legislation answered the call for the health care reform needed. The legislation included major provisions to accelerate the advancement of the standards of quality- and quality-improvement practices. As such, it introduced a new paradigm centered on value-based care delivery and payment never used before.

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Prior to and through the ACA, between 1999 and 2010, many new and improved tools of quality were introduced to better enable and facilitate enhanced health care quality related to access, cost, quality, and safety.

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The Paradigm of Measurement: Use of Quality Measures to Evaluate Quality in Health Care

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Diagram 1.0

With the complexity of systems, processes, interventions, practices, and outcomes of care inherent in the U.S. health care system, the architects of health care quality understood, at a fundamental level, that employing standardized units of measurement would be essential. Quality measures (otherwise known as performance measures) fulfill this purpose.  These are “tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.”  Here are select examples of structure, process, and outcome quality measures:

The Donabedian model of ‘structure-process-outcome’, a conceptual model that provides a framework for measuring health services and evaluating quality of health care, was employed to help determine the categories of quality measures needed.  The purpose of quality measurement is to facilitate improvement in the quality of access, processes, and outcomes of health care. It aligns fully with the principles represented in what I call the measurement mantra (Diagram 2.0).  

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Diagram 2.0

Central Governing Authority and Frameworks for Categorization of Quality Measures

The Centers for Medicare and Medicaid Services (CMS), the public health insurance division of the U.S. Department of Health and Human Services, is the central governing authority for quality measures.  In the implementation of provisions of the ACA, CMS adopted key measurement paradigms and frameworks of quality from leading health care quality organizations (see Diagram 1.0).

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The Triple Aim, for example has a three-legged framework: (1) make care better for individuals, (2) improve health for populations, and (3) reduce per capita cost. Its construct was developed in 2007 by the Institute of Healthcare Improvement (IHI). It was led at the time by Dr. Donald Berwick, one of the architects of health care quality.  CMS adopted the Triple Aim from IHI as its overall framework for evaluating the dimensions of health care quality.

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Additionally, CMS adopted the IOM-defined categorization of health care quality along six domains: (1) safety, (2) effectiveness, (3) patient-centeredness, (4) timeliness, (5) efficiency, and (6) equity.  CMS, therefore, uses the tools of quality measures and frameworks of quality (i.e., Triple Aim, six domains of quality) to evaluate the state of quality and to facilitate quality improvement in the structure, processes, and outcomes of health care.

The current CMS framework for quality is the  CMS Meaningful Measures Initiative, launched in 2017. The main purpose of this initiative is to identify high priority areas for quality improvement and measurement in order to improve outcomes for patients, their families, and providers, while reducing burden on clinicians and providers also.

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Health Care Stakeholders and Organizations Impacting or Impacted by Quality Measures

Committed, caring, and talented people work diligently in an exceedingly large number of areas where health care quality is of importance. Many of these individuals work for organizations centrally focused on quality measurement and quality improvement in healthcare.

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Here is a list of select organizations focused on quality measurement and/or quality improvement:

• The Centers for Medicare and Medicaid Services (CMS) https://www.cms.gov/
• Agency for Healthcare Research and Quality (AHRQ) https://www.ahrq.gov/
• Quality Improvement Organizations (QIOs) http://qioprogram.org/
• National Committee for Quality Assurance (NCQA) https://www.ncqa.org/
• National Quality Forum (NQF) https://www.qualityforum.org/Home.aspx
• Pharmacy Quality Alliance (where I previously worked) https://www.pqaalliance.org/
• Medical Societies
• Government Contractors (e.g., HSAG, IMPAQ, Mathematica, etc.)

Moreover, possession of a strong working knowledge of health care quality should be important to those working in organizations that are involved in the direct delivery and provision of health care services. The following list represents the types of organizations with the most direct impact on the performance of quality measures:

• Primary care practices
• Specialty medical practices
• Community mental health centers
• Ambulatory Surgical Centers
• Long-Term Care Facilities (e.g., skilled nursing facilities, nursing homes, etc.)
• Inpatient Hospitals
• Cancer Hospitals
• Outpatient Hospitals
• End Stage Renal Disease Facilities
• Inpatient Psychiatric Hospitals

Additionally, health plans hold significant accountability and financial risk for performance on quality measures in relation to the quality of services delivered to their beneficiaries.

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The following list represents types of payer organizations with accountability for quality measure performance:

• Medicare Advantage (Medicare Part C)
• Medicare Prescription Drug Plans (Medicare Part D)
• Medicaid Fee for Service
• Medicaid Managed Care Plans
• Commercial Insurance Plans

Four other types of health care organizations worthy of mention although they do not hold direct accountability or financial risk for performance on quality measures. They are: electronic health record companies, community pharmacies, pharmacy benefit managers, and pharmaceutical manufacturers.

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This is not to say that health care quality and performance on quality measures does not hold relevance for these types of organizations.  It most certainly does.  Contracting arrangements are established or at least sought between these four types of firms and organizations with direct accountability and payment risk for quality measure performance. A key takeaway, though, is that these four types of organizations do not hold direct accountability for quality measure performance.

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Lastly and most importantly, the voices and engagement of patients and caregivers in informing the conceptualization and use of quality metrics in clinical practice is vital.  While much of the work related to quality measurement is often complex and requires specialized training, the use of quality measures in health care have significant and direct implications for patients and caregivers,  Therefore, the voice of patients and families is valued highly by stakeholders involved in development of quality measures.  For consumers who want to lend their voices, I suggest contacting Patient & Family Centered Care Partners or the medical society which is related to the disease area of interest.

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Hopefully, at least at a high level, it is more apparent than before you read this article that quality measurement has something for all healthcare stakeholders, and it’s more clear now why it should matter for…policy folks, clinicians, patients and caregiver advocates, pharmaceutical manufacturers, health pans, community pharmacies, and many others.

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