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

Table 5. National sources for specific hospital performance measures

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

One of several surveys available through AHRQ. HCAHPS® surveys patients' experiences with their hospital care and services. NQF endorsed.

Survey tools and documentation resources are available at: (Survey results are posted on CMS Hospital Compare Web site.)

  • 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.

2. AHRQ Quality Indicators

Three sets of hospital QIs:
A. Inpatient Quality Indicators (IQIs) reflect quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures.
B. Patient Safety Indicators (PSIs) also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
C. Pediatric Quality Indicators (PDIs) reflect quality of care inside hospitals and identify potentially avoidable hospitalizations among children.
(A separate subset of Neonatal Quality Indicators is also available.)


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. CMS-Hospital Comparec

Publicly reports 24 clinical process-of-care indicators, 3 clinical outcome indicators, and 10 HCAHPS®-derived measures. Will begin reporting a subset of AHRQ QIs in 2010. National Quality Forum endorsed.

Available at:

Safety Several Patients who received appropriate preventive antibiotics for their surgery


  • Process
  • Outcome
  • More than 20
  • Several
  • Heart failure patients given an evaluation of left ventricular systolic (LVS) function
  • 30-day mortality rate for heart failure
Patient Centeredness Several 10 specific HCAHPS® questions
Timeliness Several Pneumonia patients given initial antibiotics within 4 hours after arrival
Efficiency Several 30-day readmission rate for heart failure
Equity NA NA
Equity NA NA

4. The Joint Commission

The Joint Commission accredits and certifies health care organizations and programs that meet certain performance standards. The Commission's core hospital measures overlap with many of the CMS hospital performance measures. NQF endorsed.

Available at:

Safety About 10 Initial antibiotic received within 6 hours of hospital arrival


  • Process
  • Outcome
More than 30 Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction
Patient Centeredness Refer to HCAHPS Refer to HCAHPS
Timeliness About 10 Aspirin at arrival for heart attack patients
Efficiency NA NA
Equity NA NA

5. Leapfrog

The Leapfrog Group is a voluntary program aimed at rewarding the health industry for improvements in health care safety, quality, and customer value. Leapfrog designed quality and safety practice measures focused on reducing preventable medical errors. NQF endorsed.

Available at: 

Safety Several Patient safety practices include practices to prevent medication errors, to ensure appropriate intensive care unit staffing, and to refer patients to other higher volume hospitals for selected high-risk procedures.


  • Process
  • Outcome
Several Specific processes of care for high-risk deliveries, weight loss surgery, aortic valve replacement, abdominal aortic aneurysm repair, pancreatic resection, esophageal resection
Patient Centeredness NA NA
Timeliness NA NA
Efficiency Several Quality/cost ratings for heart bypass surgery, heart angioplasty, heart attack, and pneumonia care. Resource utilization is based on risk-adjusted average length of stay, inflated by 14-day all-cause readmissions.
Equity NA NA

aA 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.
bClassification 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.
cMost CMS HospitalCompare measures were developed by other organizations, such as The Joint Commission, 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 5. National sources for specific hospital performance measures. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.