Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives
Selecting quality of care and resource use measures is an important and challenging task for organizations striving to improve the quality of health care in their communities. This Decision Guide is designed to inform readers about the most critical issues to consider when selecting and adopting such performance measures.
The topic of measure selection presumes that readers already have a basic understanding and comfort with many of the issues related to performance measurement. For those readers who need an introduction to performance measurement, see the box on the next page, "Why is health care performance measurement important?" for a brief summary and links to more introductory resources.
Decision Guide Format and Methodology
This Decision Guide attempts to answer 26 questions that are frequently asked, in slightly different ways, by leaders and stakeholders in community quality collaboratives across the country. These questions were fine-tuned by a panel of 10 reviewers from Chartered Value Exchanges (CVEs), representative of various geographic regions and stakeholder organizations, who were selected by the Agency for Healthcare Research and Quality (AHRQ). A draft of this Decision Guide was reviewed by the same panel and many content experts and was revised based on their suggestions.
We organized the questions into five sections that may be read sequentially or to suit the user's needs. Part I: Introduction to Performance Data presents information about sources of data, strengths and weaknesses of data, and data management strategies. Part II: Introduction to Measures of Quality discusses issues focused on quality measure construction, risk-adjustment, and specific measures used to calculate physician and hospital performance. Part III: Introduction to Resource Use/Efficiency Measures presents information about the primary types of resource use measures and the national groups developing such measures. It also discusses how these measures are used to compare providers to benchmarks. Part IV: Selecting Quality and Resource Use Measures offers different typologies and criteria for community collaboratives to consider when selecting their measures. The guide concludes with Part V: Interpreting Quality and Resource Use Measures, which addresses ways the two measure types can be evaluated together to identify high-value providers.
We recognize that each collaborative must adapt its programs to local market conditions and local concerns about health care quality. We also recognize that collaboratives, including CVEs, are in different stages of evolution, depending on when and how they were established. Therefore, some of the 26 questions may be more relevant to some collaboratives than to others. We hope that this Decision Guide fosters additional discussion within and across communities, so that leaders and stakeholders in collaboratives can share their experiences and improve their programs.
This Decision Guide uses the Institute of Medicine's (IOM) definition of quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."1 Based on this definition, quality problems are broadly categorized as problems of overuse, underuse, and misuse.2 We also build on the IOM's six domains of high-performance health care for the 21st century: safety, effectiveness, patient centeredness, timeliness, efficiency, and equitability. These concepts and their applicability to selecting quality of care and resource use measures will be further explained in the sections that follow.
This Decision Guide focuses on hospital and physician data and measures, but some of the underlying principles or criteria may also apply to selecting health plan, nursing home, or home health quality measures. The sources of data and measures are numerous and constantly changing; Web links are embedded throughout the Guide with the intent of producing a "living" document that is as current as possible.
Before selecting measures, stakeholders should come to agreement as to why they are measuring quality because the goals of measurement can affect the types of measures selected and how they are prioritized. For example, programs focused on driving quality improvement within health care organizations may emphasize process-of-care measures, whereas programs focused on engaging consumers may emphasize outcome and patient experience measures, which are typically more salient to consumers.
Why is health care performance measurement important?
Two interrelated factors justify the efforts of community quality collaboratives to assess health care performance: substantial variation in the quality of care and the cost of that care. Numerous studies have shown that unexplained variation in quality due to underutilization, overutilization, and inappropriate care leads to unnecessarily high mortality and morbidity rates.3-6 In addition, the cost of health care in the United States exceeded $2.2 trillion in 2007, representing more than 16% of the gross domestic product.7 One can surmise that a significant portion of these expenditures was misspent, as research has shown that high-quality care is often associated with lower or equal cost.8,9
Over the last 20 years, performance measurement has gained momentum through the efforts of public and private sector stakeholders that are interested in improving care. Measurement results are used privately to guide quality improvement within organizations and publicly for policy planning. Within the last decade, public reporting and financial incentive (pay-for-performance) programs have emerged. Measurement supports the transparency required for accountability and quality improvement in the health care system. Efforts to measure quality and cost have thus become widespread throughout the public and private sectors.
Several sources for introductory information about performance measurement and quality of care can be found at:
- Community Quality Collaboratives
Organizations of stakeholders working together locally to transform health care
- Tools, resources, meeting summaries, consumer information, and speeches
- National Healthcare Quality Report, National Healthcare Disparities Report, Quality Indicators, and other tools and resources
- Talking Quality
Guidance for sponsors of consumer reports on health care quality
- Commonwealth Fund
Private foundation focused on improving health care quality; produces more than 100 free publications each year
- National Quality Forum
Nonprofit organization that aims to improve the quality of healthcare for all Americans