Clinical Quality Measures: What They Are and Why They Matter

What is “healthcare quality”? Luckily, experts have published foundational works that help provide a model for understanding. A widely cited framework, called the Triple Aim, highlights three domains: improving patient experience, improving the health of populations, and reducing per capita costs. A subsequent model entitled the Quadruple Aim also incorporated improving the healthcare provider experience. Figuring out what to emphasize and how to measure it depends on who’s asking. Patients may have a different view from clinicians, health systems, and payers. 

For instance, a specific patient may focus on the doctor-patient relationship, how they felt they were treated, or whether they had a good outcome. Of course, patient experience can be tracked and play a role in reimbursement through patient satisfaction surveys like HCAHPS. Health systems pay close attention to patient experience, but are also reviewing granular data around mortality, readmission rates, and other metrics that affect cost, revenue, efficiency, and patient care.

Healthcare organizations track these metrics - oftentimes referred to as clinical quality measures (CQMs) - to ensure they’re providing safety and high standards of care at a cost that’s sustainable as a business. 

Some organizations like the National Committee for Quality Assurance (NCQA), the creators of HEDIS measures,  are dedicated to creating high quality measures. However, as anyone can theoretically define a quality measure, organizations like the National Quality Forum (NQF) vet and endorse quality measures. Some of these quality measures are then adopted for use in operational and reimbursement agreements. Many of those measures are tracked and evaluated by health systems. Oftentimes, executive teams, either the C-suite (CEO, CFO, CIO, etc.), a quality committee, or board of trustees, decide which measures to track most closely based on an assessment of the opportunity to reduce cost and/or increase revenue, improve patient experience, or patient safety and outcomes. While the importance of certain quality measures more specifically may differ from health system to health system, many health systems tend to track the most costly and dangerous conditions closely, especially those with higher mortality and/or readmission rates, including:

• Sepsis 
• Catheter-associated urinary tract infection (CAUTI)
• Central-line-associated bloodstream infection (CLABSI) 
  
  

How else is healthcare quality measured? 

While a healthcare system will track quality measures internally to identify areas for improvement, certain quality measures are required to be reported to payers and regulators.  

So although each provider may have its own ideas around which metrics to track and why (and we’ll get into that in our next blog post), what often matters most is what they’re reporting to payers like the U.S. government; those metrics affect their reimbursement and ultimately, public perception. Increasingly, the federal government is publishing these quality metrics online in order to support patients.

As part of a pay-for-quality program, payers designate which quality measures need to be tracked and reported. The Centers for Medicare & Medicaid Services (CMS - www.cms.gov), for example, might pay bonuses or penalize providers based on their relative CQM performance compared to other providers.  CMS has established programs focused on inpatient care like the Hospital Inpatient Quality Reporting (IQR) program, but also ambulatory-focused programs like the Merit-based Incentive Payment System (MIPS).

Payers establish their own criteria around the quality measures they require providers to report and each payer’s value-based care program varies. However, some example CQMs that payers may require to be reported across various clinical practices include:

• A maximum number of visits to the Emergency Department (AMB-ED)
• Percentage of lead screening for children (LSC)
• Readmission rates for all causes/conditions
• Percentage of developmental screenings in the first three years of life
  
  

CMS, which falls under the U.S. Department of Housing and Human Services (www.hhs.gov), establishes and tracks their own set of quality measures (CQMs)  to evaluate the quality of healthcare services provided by eligible professionals, defined as providers who are paid based on Medicare Physician Fee Schedule (MPFS).

CMS-mandated CQMs also vary from year to year, based on changing demographics, new treatments, and myriad other factors, but all CMS CQMs fall into the following categories: 

• Health outcomes
• Clinical processes
• Patient safety
• Efficient use of healthcare resources
• Care coordination
• Patient engagement 
• Public health and population health
• Adherence to clinical guidelines
  
  

Much like commercial payers, CMS has implemented a quality payment incentive program, known as the Quality Payment Program (QPP), which rewards healthcare value and outcomes, as reported through CQMs. By using incentives to improve levels of care provided to patients, CMS is working toward a more patient-focused era in healthcare. 

To align with that goal, CMS has two primary objectives around the CQM requirement:

Improve the quality of healthcare provided to patients

• CMS considers CQMs a tool for “making good decisions” that:
• Make it more likely patients and providers will experience a positive result
• Make it less likely patients and providers will experience an adverse result
• Empower low-performing clinicians to choose to allocate resources to becoming high-performing healthcare providers

Empower patients to make informed decisions

• Patients can use public information derived from CMS’ quality measure reports to select high-performing providers
  
  

Where tracking quality measures gets tricky

Definitions around quality measures differ from group to group and even from provider to provider. For instance, a health system may define “readmission within 30 days” in different ways based who is defining the measure, how specific the instructions around the measure are, and available data.

Also, while payer and CMS-defined quality measures are necessary for the provider to track for reimbursement, some of those core measures may not be the provider’s top priorities; they may be tracking other measures that have a bigger impact on their revenue and operations. This can overwhelm providers, who will need to track different metrics for each commercial payer, plus CMS (and possibly for other patient registries and research organizations), without negatively impacting outcomes that they’re not actively following. 

Regardless of who’s requiring quality measures - all stakeholders can agree that the goal around tracking and reporting on quality is to improve the overall value of the healthcare industry to society through lower costs, better outcomes, and a better patient and provider experiences. Analyzing EHR data, using health informatics, and implementing an iterative quality improvement model can enable healthcare organizations to reach their CQM goals.