Major Hospital Quality Measurement Sets
You can use a number of valid and reliable hospital measurement sets as the basis for collecting data and preparing comparative information for your audience. The five measure sets listed here have been endorsed by the National Quality Forum.
- AHRQ Quality Indicators.
- National Hospital Quality Measures.
- CAHPS Hospital Survey.
- The Leapfrog Group’s Measures.
AHRQ Quality Indicators
The AHRQ Quality Indicators (QIs) comprise four measure areas: inpatient, prevention, patient safety, and pediatric care. The measures were originally developed for several purposes, including quality improvement, pay-for-performance, and public health monitoring. Three of the four indicator sets are considered appropriate and useful for public reports as well:
- The Inpatient Quality Indicators (IQIs) capture quality of care inside hospitals. They include inpatient mortality for certain procedures and medical conditions; utilization of procedures for which there are questions of overuse, underuse, and misuse; and volume of procedures for which there is some evidence that a higher volume of procedures is associated with lower mortality.
- The Patient Safety Indicators (PSIs) identify adverse events occurring during hospitalization. They provide information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth.
- The Pediatric Quality Indicators (PedQIs) include measures of inpatient quality and patient safety specifically for the pediatric population.
Composite Measures: In 2006 and 2007, AHRQ supported the development of composite measures of inpatient quality, patient safety, and pediatric quality based on the individual indicator sets. Researchers relying on sophisticated statistical techniques as well as expert opinion developed four composite measures. These measures combine scores for individual hospitals on selected QIs to generate a more “global” assessment of hospital performance.
Learn more about the development of the AHRQ QI composite measures for inpatient quality, patient safety, and pediatric quality:
- Inpatient Quality Indicators (IQI) Composite Measure Workgroup Final Report, March 2008.
- Patient Safety Indicators (PSI) Composite Measure Workgroup Final Report, March 2008.
- Prevention Quality Indicators (PQI) Composite Measure Workgroup Final Report, April 7, 2006.
Data Source: The AHRQ QIs use inpatient administrative data that is available from individual hospitals, a statewide association or data organization, or a State agency. Another source of administrative data for populating the AHRQ QIs measures is the Healthcare Cost and Utilization Project (HCUP). Learn more in the section on databases.
National Hospital Inpatient Quality Measures
The National Hospital Inpatient Quality Measures are the product of a collaboration on hospital measurement and reporting between the Centers for Medicare & Medicaid Services and the Joint Commission. The National Hospital Inpatient Quality Measures assess clinical effectiveness and 30-day mortality associated with major health conditions.
Data Source: Data for the National Hospital Inpatient Quality Measures are available from Hospital Compare, a public Web site hosted by the Department of Health & Human Services.
ORYX is a set of performance measures required by The Joint Commission. Hospitals seeking accreditation from The Joint Commission must submit some combination of ORYX measures to fulfill the requirements; the measures are also meant to support organizations in their quality improvement efforts.
Data Source: Data from the ORYX measures are available on The Joint Commission’s Quality Check®, a free public quality report.
CAHPS Hospital Survey—Adult Version
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, commonly known as Hospital CAHPS or HCAHPS, is a standardized survey instrument for measuring adult patients' perspectives on care they experience during a hospital stay. HCAHPS addresses critical aspects of the hospital experience, including:
- Communication with doctors and with nurses.
- Responsiveness of hospital staff.
- Hospital cleanliness and quietness.
- Communication about medicines.
- Discharge information and patients’ understanding of care when leaving the hospital.
Patients are also asked to rate the hospital overall and their willingness to recommend the hospital to others.
Download the CAHPS Hospital Survey and learn more about its implementation.
Data Source: Scores from the CAHPS Hospital Survey are available from the Hospital Compare Web site.
CAHPS Child Hospital Survey
The CAHPS Child Hospital Survey is a standardized survey instrument that asks about the experiences of pediatric patients and their parents or guardians with inpatient care. This survey asks about various aspects of patient experience that are important to children and their parents/guardians; the 16 measures cover the following four topics:
- Communication with the parent.
- Communication with the child.
- Attention to safety and comfort.
- Hospital environment
Respondents also provide an overall rating and indicate their willingness to recommend the hospital.
Data Source: Scores for participating hospitals are available from the Leapfrog Group’s hospital report.
The Leapfrog Group’s Measures
The Leapfrog Group, an employer-based coalition, develops and maintains a measure set that focuses on hospital quality and safety practices. Hospitals voluntarily submit information on the extent to which they adhere to certain quality and safety practices using the Leapfrog Hospital Survey tool.
The Leapfrog measures address crucial areas, or “leaps,” such as:
- Do physicians enter prescriptions and other orders into computerized medication systems?
- How many high-risk surgeries are conducted at the hospital?
- How consistently does the hospital provide appropriate care to women giving birth and newborns?
- Are hospital intensive care units (ICUs) staffed by qualified specialists?
- Do hospitals have safety practices and policies advocated by the National Quality Forum to reduce harm and errors?
Data Source: The Leapfrog Group scores the hospital respondent’s results and publicly reports the results for free on their Web site.
Also in "Measures of Hospital Quality"
- Examples of Hospital Quality Measures for Consumers
- Major Hospital Measurement Sets
- Databases Used for Hospital Quality Measures