Describe How a Plan or Provider Can Influence a Quality Measure

For some measures, it may be necessary to explain what the plan or provider can do to improve its performance. Providers are often concerned that they are being rated on measures over which they believe they have limited influence. When the public is asked about quality measures, they also worry about holding a provider responsible for something they do not control or even influence. The public wants quality reports to be fair so that they are not judging plans or providers on things they cannot change.

For example:

  • In the testing of candidate measures for HEDIS 3.0, people in focus groups did not think that health plans should be held accountable for whether or not their members got a mammogram in a timely way.1 “That’s between me and my doctor,” they said.
  • Several hospital quality measures have been identified as “nursing sensitive,” which means that performance on the measure is strongly influenced by the care delivered by nurses. One of them is the rate of infections in central lines. On first being presented with this measure, recent hospital patients thought that the central line would almost always be placed by a doctor, so the nurse should not be held accountable if an infection occurred. When it was explained that nurses are responsible for checking on the central line and keeping it clean and germ-free, they accepted that the nurse did indeed have influence over the measure.

The most straightforward strategy is to have a section entitled “What can “x” do about this measure?” with a one-sentence explanation, as close to the measure as possible. An alternative is to have a more general statement covering all measures that describes the way that health plans, hospitals, or whatever is being rated can influence the measures.

EXAMPLE: How Plans or Providers Can Influence the Measure

Title: Keeping Patients Safe
Sponsor: Massachusetts General Hospital (MGH)
Massachusetts General Hospital has included a paragraph or two about what the hospital is doing to improve its performance for the measures listed on its site. The text included below shows what MGH is doing to reduce the rate of patients getting peptic ulcers at the hospital. (To view complete information, go to

“What are we doing to improve?

Overall, the rate of patients who have pressure ulcers at MGH is low. We achieve this by focusing on prevention. When a patient is admitted to the hospital, a nurse assesses the condition of the patient's skin and incorporates appropriate interventions (e.g., frequent turning, a nutrition consult) into the patient's plan of care. To ensure that nurses have the necessary knowledge for skin assessment and intervention they attend a Phase I Wound Care Education Program shortly after they are hired. They are also supported in their work toward pressure ulcer prevention by their local Clinical Nurse Specialist. Bed surface is a key factor in preventing pressure ulcers. To that end, MGH has recently purchased beds with surfaces that will help to keep the skin of our patients intact. The highest percentage of pressure ulcers occur in our intensive care areas where our patients have complex conditions that compromise the body's ability to keep the skin healthy."

Source: Massachusetts General Hospital. Massachusetts General Hospital: Quality & Safety. Available at
1 McGee J, Sofaer S, Kreling B. Final Report: Findings from Focus Groups Conducted for the National Committee for Quality Assurance Medicare and Medicaid Consumer Information Projects, July 1996.

Also in "Describing Measures in User-Friendly Ways"

Page last reviewed March 2016
Page originally created February 2015
Internet Citation: Describe How a Plan or Provider Can Influence a Quality Measure. Content last reviewed March 2016. Agency for Healthcare Research and Quality, Rockville, MD.
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