Understanding Quality Measurement

Child Health Care Quality Toolbox

The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.

What Is Quality?

The Institute of Medicine defines health care quality as "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Quality Domains

The Institute of Medicine further defines quality as having the following properties or domains:

Institute of Medicine (IOM) Domains

Effectiveness. Relates to providing care processes and achieving outcomes as supported by scientific evidence.

Efficiency. Relates to maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used.

Equity. Relates to providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care.

Patient centeredness. Relates to meeting patients' needs and preferences and providing education and support.

Safety. Relates to actual or potential bodily harm.

Timeliness. Relates to obtaining needed care while minimizing delays.

The Child Health Care Quality Indicators at a Glance Matrix included in this toolbox provides some guidance about the domains included in child quality measurement sets. It is important to note that some measurement sets include measures for more than one domain.

Online Resource: For the Indicators at a Glance Matrix, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/indicators/index.html

Consumer Perspectives

Another part of the IOM's framework looks at consumer perspectives of health care needs. Reporting categories were developed based on Foundation for Accountability (FACCT) research showing how consumers think about their care. The categories are:

  • Staying Healthy. Getting help to avoid illness and remain well.
  • Getting Better. Getting help to recover from an illness or injury.
  • Living with Illness or Disability. Getting help with managing an ongoing, chronic condition or dealing with a disability that affects function.
  • Coping with the End of Life. Getting help to deal with a terminal illness.

Online Resources:

For more information about the Institute of Medicine and its work on health care quality, go to: http://nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx.

What Is Quality Measurement for Children?

Quality measurements typically focus on structures or processes of care that have a demonstrated relationship to positive health outcomes and are under the control of the health care system. Technically, AHRQ defines a quality measure as a mechanism to assign a quantity to quality of care by comparison to a criterion. Health care quality measurement for children is the process of using a scientifically sound tool to assess the extent to which children are receiving quality health care in any of the IOM quality domains. "Quality measures" can be used to evaluate a:

  • Managed care organization (MCO).
  • Health plan or program.
  • Hospital.
  • Health care practitioner.

Online Resource: For more information on quality domains, go to: http://www.ahrq.gov/chtoolbx/understn.htm#domains

To use quality measurement, there needs to be a responsible entity that:

  • Can be identified.
  • Is held accountable for its observed behavior.
  • Has a reasonable degree of control over the aspect of care being evaluated.

The term "measurement" implies that the approach being used is:

  • Rigorous.
  • Systematic.
  • Quantifiable.

Online Resource: For more information on quality measures, go to the glossary at AHRQ's National Quality Measures Clearinghouse (NQMC) at http://www.qualitymeasures.ahrq.gov/index.aspx. The NQMC provides information on 74 child health measures.

How Is Quality Measurement Used?

Quality measurement is a type of evaluation that is used in many industries.

Example: The Environmental Protection Agency measures the quality of the air in the surrounding environment by analyzing the presence of specific compounds that are known to cause pollution. The resulting calculation, known as the Air Quality Index, tells you how clean the air is and whether it will affect your health.

Quality measurement is now increasingly common in health care.


  • The percentage of children age 2 who receive the appropriate immunizations. This is determined by dividing the number of children age 2 with the appropriate immunizations by the total number of children age 2 in the applicable population (health program, MCO, State, etc.).
  • The percentage of parents reporting "not a problem" in obtaining a specialist referral for their child. This is determined by dividing the number of parents reporting "not a problem" by the total number of parents in the applicable population who have requested a specialist referral for their child.

What Does Quality Measurement Require?

A quality measurement tool must:

  • Be objective.
  • Be based on scientific evidence.
  • Not affect or distort results.

In health care quality measurement today, expert consensus is often used to reach agreement on precise definitions and measurement specifications. In developing a quality measure, it must be tested to ensure that it is:

  • Reliable. Use of the tool results in the same reading regardless of who does the measuring or when and where the measurement is taken.
  • Valid. The tool measures what is intended.
  • Standardized. Definitions of data elements, data collection, and data analyses are sufficiently precise and comprehensible that they can be understood and applied in the same way regardless of who refers to or applies them.

The further a measure is from these ideal technical conditions, the greater the difficulty will be in using the measurement information to compare health plan or program results or in answering specific questions about the health care being provided.

What Do Quality Measurement Results Tell Us?

Quality measurement results describe an observed level of activity (immunization rate, rate of parental satisfaction with referrals) but not why the level is as it is. Results cannot reveal which factors account for differences in measured levels of quality.

Example: Factors affecting immunization rates may include:

  • Provider payment systems.
  • Parental or provider education.
  • Cultural differences.
  • Underlying economic issues.

Answers to such questions require additional investigation and may serve as the starting point for program management initiatives or quality improvement efforts.

The use of quality measurement in health care is becoming common, but it is important to bear in mind concerns about:

  • Problems with data availability, accuracy, and completeness.
  • Differences in definitions of basic terms.
  • Failure to meet standards of reliability, validity, and standardization.

Online Resources:

For more information on program management, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/uses/index.html#mgmt

For more information on quality improvement, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/uses/index.html#quality

What Types of Measures Can We Use?

Categories of Measures

Quality measures can apply to various aspects of health care. Although there is no standardized set of categories, the categories, structure, process, and outcomes developed by Avedis Donabedian, M.D., a pioneer in the science of measuring health care quality, are still widely used today. Structure, process, and outcomes measures can be used to measure any of the IOM quality domains noted above.

Online Resource: For more information on quality domains, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html#domains

Structure. The resources and organizational arrangements are in place to deliver care.


  • Number of nurses per patient.
  • Percentage of physicians who are board certified.
  • Presence of quality improvement programs.

Accreditation by recognized national organizations, such as the National Committee for Quality Assurance or the Joint Commission, is based in part on assessment of structural characteristics.

Online Resources:

For more information on the National Committee for Quality Assurance, go to: http://www.ncqa.org/

For more information on the Joint Commission, go to: https://www.jointcommission.org/

Process. Appropriate physician and other provider activities are carried out to deliver care.


  • Percentage of females of specified age receiving mammography.
  • Percentage of patients with asthma for whom appropriate medications are ordered.
  • Number of times adolescents are provided guidance on smoking avoidance.

Outcomes. The results of physician and other provider activities.


  • Number of patients successfully treated.
  • Test results within a range indicating effective functioning.
  • Number of avoidable complications and deaths.
  • The experience with health care and/or the level of satisfaction with care.

Conclusions about quality based on outcomes could be inaccurate if outcomes are not adjusted to determine whether patient characteristics or actual quality of care most affected the results. Techniques for making such adjustments are complex.

However, adjusting quality measures based on patient characteristics may obscure differences in performance among various groups. Knowledge that quality differs by age, race, or other characteristics may be important in its own right.

Multiple Measures

Some users of quality measurement choose multiple measures of the specific aspect of health care they wish to assess in order to get a more complete picture of performance.

Example: To assess the quality of a health plan or program in delivering health care to enrolled children, a State agency may choose to use several parental perception measures as well as several measures of the delivery of preventive care.

How Can We Interpret Results?

Well-established standards of care exist for some areas of health care treatment and services. It is thus possible, in these areas, to say that a rate is "high" or "low" or that a quality problem does or does not exist.

Example: Standards exist for the appropriate types, number, and timing of vaccinations for children. Thus, rates are easily determined and compared.

However, no well-established standards exist with regard to the appropriate number of emergency room visits for children with asthma. Because emergency room visits for such children theoretically can be eliminated with appropriate ambulatory care, lower rates are considered "better" than higher ones. However, there is no scientific basis for saying that a given rate is "too high" or "too low." Thus, a given rate may or may not indicate the presence of a quality problem.

AHRQ's National Quality Measures Clearinghouse™ notes several standards for comparing your quality measurement results to previous performance or to others' performance. These include an external comparison at a point in time, an external comparison of trends over time, and an internal comparison at two or more points in time.

Rates can be benchmarked through comparison with actual State, regional, or national levels. Such comparisons are increasingly available.

Online Resources:

Rates can also be compared with goals set by such programs as Healthy People 2020 and Bright Futures where applicable goals exist.

When rates fall outside of normally observed ranges or well below established goals, investigation may be in order. Program management or quality improvement initiatives may be considered.

Online Resources:

For more information on Healthy People 2020, go to: http://www.healthypeople.gov/

For more information on Bright Futures, go to: http://www.brightfutures.org/

For more information on program management, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/uses/index.html#mgmt

For more information on quality improvement, go to: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/uses/index.html#quality

Want More Information?

You can get more information on current discussions concerning definitions of health care quality measurement and quality through review of one or more of the following documents:

Agency for Healthcare Research and Quality. The National Healthcare Disparities Report. Rockville (MD): Agency for Healthcare Research and Quality; 2003 Jul. Go to: https://archive.ahrq.gov/qual/nhdr03/nhdr03.htm

Agency for Healthcare Research and Quality. The National Healthcare Quality Report. Rockville (MD): Agency for Healthcare Research and Quality; 2003 Dec. Go to: https://archive.ahrq.gov/qual/nhqr03/nhqr03.htm

Beal AC, Co JP, Dougherty D, et al. Quality measures for children's health care. Pediatrics 2004 Jan;113(1 Pt 2):199-209.
Abstract available on PubMed®: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14702502&dopt=Abstract

Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966 Jul;44(3):Suppl:166-206. No abstract available.

Dougherty D, Simpson LA. Measuring the quality of children's health care: a prerequisite to action. Pediatrics 2004 Jan;113(1 Pt 2):185-98.
Abstract available on PubMed®: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14702501&dopt=Abstract

Ferris TG, Dougherty D, Blumenthal D, et al. A report card on quality improvement for children's health care. Pediatrics 2001 Jan;107(1):143-155.
Abstract available on PubMed®: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11134448&dopt=Abstract

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. Go to: http://www.nationalacademies.org/hmd/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Institute of Medicine Committee on the National Quality Report on Health Care Delivery. Envisioning the national health care quality report. Washington (DC): National Academy Press; 2001. Go to: https://www.nap.edu/catalog/10073/envisioning-the-national-health-care-quality-report

Institute of Medicine. Guidance for the National Healthcare Disparities Report. Washington (DC): National Academy Press; 2002. Go to: https://www.nap.edu/catalog/10512/guidance-for-the-national-healthcare-disparities-report

Kuhlthau K, Ferris TG, Iezzoni LI. Risk adjustment for pediatric quality indicators. Pediatrics 2004 Jan;113(1 Pt 2):210-6.
Abstract available on PubMed®: https://www.ncbi.nlm.nih.gov/pubmed/14702503?dopt=Abstract

Mangione-Smith R, McGlynn EA. Assessing the quality of healthcare provided to children. Health Serv Res 1998 Oct;33(34):1059-90.
Abstract available on PubMed®: https://www.ncbi.nlm.nih.gov/pubmed/9776949?dopt=Abstract

Page last reviewed November 2017
Page originally created September 2012
Internet Citation: Understanding Quality Measurement. Content last reviewed November 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html