Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives

Table 4. National sources for specific physician performance measures

Physician Performance Measures
Measure Source and Description IOM Domaina Number of Measures Availableb Measure Example

Clinician and Group CAHPS® patient experience survey. Includes core questions for adult primary care physician (PCP), adult specialist, and child PCP surveys. Supplemental Items are also available. NQF endorsed.

Available at:

  • Process
  • Outcome
Patient Centeredness A few primary composites in core survey and supplemental items that include numerous individual measures

Composite: How Well Doctors Communicate

Some Individual Measures included in the composite: Did the doctor listen carefully to you; show respect for what you had to say; spend enough time with you…?

Timeliness A few primary composite measures in core survey and supplemental items that include numerous individual measures

Composite: Getting Appointments and Health Care When Needed

Some Individual Measures included in the composite: Did you obtain an appointment for routine care as soon as you needed; receive an answer to your question the same day from the doctor's office; see the doctor within 15 minutes of your appointment time?

Efficiency NA NA
Equity NA The survey does capture sociodemographic information, which may permit some equity analysis of the other measures.


CMS established a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services for Medicare beneficiaries. CMS uses 179 PQRI quality measures (2010) constructed by other measure developers (primarily NCQA and Physician Consortium for Performance Improvement® [PCPI], but also scientific groups such as the American Heart Association and American Stroke Association). Most are NQF endorsed or pending review.

Available at:

Safety About 20

Medication reconciliation (within 60 days postdischarge) between discharge medications and current medication list in medical record from ongoing care physician

(Most safety measures are related to surgical care)


  • Process
  • Outcome
More than 100 Asthma assessment for number of daytime or nocturnal asthma symptoms
Patient Centeredness Several Consideration of rehabilitation services documented for stroke patients.
Timeliness More than 20 Antidepressant medication prescribed during acute phase (first 12 weeks) for patients with new episode of major depression
Efficiency   Measures of overuse of potentially ineffective interventions (see NCQA and PCPI)
Equity NA NA

3. National Committee for Quality Assurance (NCQA)

NCQA sponsors the Healthcare Effectiveness Data and Information Set (HEDIS), which includes measures of both health plan and physician performance. NCQA also sponsors Physician Recognition Programs for back pain, heart/stroke, diabetes, physician practice connections, and patient-centered medical homes. Most measures are NQF-endorsed.

Available at:

Safety Several Potentially harmful drug-disease interactions in the elderly, medication reconciliation postdischarge


  • Process
  • Outcome
More than 30 Childhood immunization status, Immunization for adolescents, Breast cancer screening
Patient Centeredness Several as part of Back Pain Program An ongoing system for obtaining feedback about patient experience with care, Use of shared decisionmaking
Timeliness Several Followup after hospitalization for mental illness
Efficiency Several Measures of overuse of potentially ineffective interventions, such as Avoidance of antibiotic treatment in adults with acute bronchitis


The American Medical Association (AMA)-convened PCPI is involved in the development, testing, and maintenance of evidence-based clinical performance measures for physicians. At the time of publication, 111 measures were National Quality Forum (NQF)-endorsed and 150 were AQA Alliance approved.66

Available at

Safety Several Risk assessment for falls


  • Process
  • Outcome
More than 200 Medication reconciliation (geriatric measure); Stenosis measurement in carotid imaging reports (radiology measure)
Patient Centeredness Several Advanced care plan (geriatrics)
Timeliness Several Aspirin at arrival for acute myocardial infarction
Efficiency Several Measures of overuse of potentially ineffective interventions, such as Avoidance of inappropriate use of antihistamines or decongestants, systemic antimicrobials, etc., for otitis media with effusion
Equity NA NA

a A single measure may belong to more than one domain. IOM definitions:
Safety — avoiding injuries to patients from the care that is intended to help them
Effectiveness — providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit
Patient centeredness — providing care that is respectful and responsive to individual patient preferences, needs, and values
Timeliness — reducing waits and sometimes harmful delays for both those who receive and those who give care
Efficiency — avoiding waste, including waste of equipment, supplies, ideas, and energy
Equity — providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
There are very few measures specifically designed to meet the IOM Equity domain criteria; however, Equity can be measured using almost any quality indicator if sociodemographic data are collected and linked to the indicator.
b Classification of measures is somewhat subjective in nature, so this column only approximates the distribution of measures across IOM domains. For example, the same measure of appropriate utilization could be interpreted as a measure of effectiveness or as a measure of efficiency.
c Most CMS PQRI measures were developed by other organizations, such as the AMA's Physician Consortium for Performance Improvement and the NCQA, so the same quality indicator may be referenced in multiple rows of this table.

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Page last reviewed October 2014
Internet Citation: Table 4. National sources for specific physician performance measures. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.