BY REBECCA PEREZ, MSN, RN, CCM
Everyone aspires to provide quality healthcare. The definition of healthcare quality would seem straightforward; however, establishing metrics is not necessarily so straightforward, a point recognized by Avedis Donabedian, a Lebanese physician and founder of the study of healthcare quality over half a century ago. In 1966, Dr. Donabedian recommended applying to standards of quality a commitment to objective science. He believed in logic, evidence, analysis and scientific inquiry (Berwick, 2016). He also introduced the trinity of structure, process and outcome measurement methods. Near the end of his life, Dr. Donabedian worried that quality improvement would become an industrial model. He famously shared in an interview, “The secret to quality is love; the love you have for your patient, the love of your profession, and the love for your God.”
Quality measurements are one way to evaluate the care delivered and the impact of that care. Accountability is also part of quality measurement, holding providers and health plans responsible for their care and services and the ability to express and publish accomplishments and successes. Our legislative and executive branches can also use quality measurements to assess a program’s strengths or weaknesses and ascertain if the intended results were achieved.
How are quality measures developed? The Centers for Medicare & Medicaid Services look to the National Quality Forum to assist in developing such measures. The National Quality Forum was established in 1999 after President Bill Clinton established the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry and concluded that patient protection and healthcare quality were needed. As a result, a coalition of public- and private-sector leaders was created to establish quality measures and public reporting. This coalition became the National Quality Forum (NQF), the only consensus-based healthcare organization as defined by the Office of Management and Government. Our federal government relies on NQF to define measures of healthcare practices as the best evidence-based approaches to improving care. Measures endorsed by NQF guide the federal government, states and private sector organizations in evaluating performance and then sharing this information with patients and families. All measures endorsed by NQF must meet rigorous criteria.
To determine if patients know their care is good, as well as the steps needed to improve outcomes and that payers are reimbursing for the best care available, performance measures are needed. Performance measures drive improvement, inform consumers and influence payment. NQF assisted with prioritizing goals outlined by the National Priorities Partnership and the office of the Secretary of Health and Human Services. Proposed quality measures can come from many sources.
NQF recommends a portfolio of tools to determine whether a submitted measure will prove useful. These tools include process, outcomes, patient experience, structural and composite measures. So, in other words, does the proposed quality measure indicate if an expected action was completed, or does the process result in the expected care results?
NQF assembles committees comprised of multiple stakeholders in standing committees that focus on topical areas for review and recommendation of quality measures. Specialty societies develop 30% of NQF-endorsed measures. Physicians primarily chair NQF committees, but the committee members include physicians, nurses, pharmacists, mental health professionals, public health professionals, social work professionals, patient advocates and consumers. Since its inception, NQF has and continues to develop quality measures. The following is a partial list of focus areas (this is by no means a comprehensive or complete listing):
- Health and Well-Being
- Rural health
- Renal measures
- Population health framework
- Behavioral health measures
- Healthcare workforce
- Prevention and Leading Causes of Death
- Cardiovascular measures
- Pulmonary measures
- Cost and resource measures
- Person- and Family-Centered Care
- Home and community-based services
- Person-centered care outcomes
- Disparities and cultural competence measures
- Patient-reported outcomes
- Effective Communication and Care Coordination
- Care coordination measures
- Multiple chronic conditions measurement framework
- Safety and care coordination for families
- Regionalized emergency medical care services
- Patient Safety
- HIT safety measures
- Patient safety measures
- All-cause readmission
- Health workforce
- Affordable Care
- Linking cost and quality measures
- Cost and resource use measures
- Affordable care measures
- Palliative and End-of-Life Care
- Care coordination measures
- Nursing home measures
- Performance measurement: care coordination for hospice and palliative care
- Multiple chronic conditions measurement framework
- Review of measures across all of NQF’s work evaluating and emphasizing disparities
- Health IT
- Critical paths for creating data platforms
- Health IT knowledge base
- Measure authoring tool for the creation of eMeasures
- Electronic clinical quality measures (eCQMs)
Case managers are often called upon to participate in collecting and reporting data for these measures. CMSA has a seat on several committees to ensure the case manager’s voice is heard and contributes to developing these measures. The committees CMSA has been involved with are All-Cause Readmissions, Opioid Measures, and Electronic Health Record Care Communication and Coordination.
Let us examine one of the All-Cause Readmissions measures to understand better how NQF is endorsing a measure. A key to overall improvement is the reduction of admission and readmission rates. High rates of hospital admissions are costly to our healthcare system and indicate low-quality care and poor care coordination. Existing strategies for improvement are reduction in hospital-acquired conditions, improved communication of discharge instructions, effective care coordination with post-acute and primary care providers and patient/family/caregiver education and support. However, we still struggle with reducing admissions and readmissions because of the lack of accountability measures.
An example reviewed and endorsed by NQF related to admissions and readmissions is Hospital 30-day Post-Hospital AMI Discharge Care Transition Composite Measure (National Quality Forum, 2011). The measure examines the incidence of readmission 30 days following discharge from an inpatient stay for a patient with a primary diagnosis of heart failure. These readmissions include readmissions, emergency department visits and evaluation and management services. This measure is associated with care coordination after discharge.
Negative reimbursement may be tied to high readmission rates, so the measure requires providers to examine why these readmissions occur and implement improvements. NQF releases all measures under review, and they are made available for public comment before endorsement. At present, NQF has released 52 measures for public comment.
To learn more about the National Quality Forum, endorsed measures and measures under review, visit: https://www.qualityforum.org/about_nqf/work_in_quality_measurement/
Berwick, D. a. (2016, June). Evaluating the Quality of Medical Care”: Donabedian’s Classic Article 50 Years Later. Milbank Quarterly, 94(2), 237-241. doi: doi: 10.1111/1468-0009.12189.
Narional Quality Forum. (2022). NQF- What We Do. Retrieved from National Quality Forum: https://www.qualityforum.org/what_we_do.aspx.
National Quality Forum. (2011, January 11). 30-Day All-Cause AMI Discharge Care Transition Composite Measure. (C. f. Services, Ed.) Washington, DC. Retrieved from https://www.qualityforum.org/Qps/QpsTool.aspx#qpsPageState=%7B%22TabType%22%3A1,%22TabContentType%22%3A3,%22SearchCriteriaForStandard%22%3A%7B%22TaxonomyIDs%22%3A%5B%5D,%22SelectedTypeAheadFilterOption%22%3A%7B%22ID%22%3A33954,%22FilterOptionLabel%22%3A%2.
Rebecca Perez, MSN, RN, CCM, is an experienced RN with a master’s degree in nursing and years of experience in case management. She is a certified case manager, a member of the Gamma Omega Chapter of Sigma Theta Tau International Nursing Honor Society and Capella University’s National Society of Leadership and Success.
Rebecca is the author of numerous professional articles and the primary author for CMSA’s CMAG 2020. She is also the co-author of CMSA’s Integrated Case Management: A Manual for Case Managers by Case Managers, and a developer of the Integrated Case Management Training Program, as well as a master trainer.
Rebecca joined in 2020 as the Senior Manager of Education and Strategic Partnerships for the and was appointed to the Leadership Consortium for the National Quality Forum in 2022.