Quality Measurement and Quality Improvement

What is quality improvement? 

Quality is defined by the National Academy of Medicine as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations. Structure includes things like technology, culture, leadership, and physical capital; process includes knowledge capital (e.g., standard operating procedures) or human capital (e.g., education and training).

How do quality measurement and quality improvement work together?

Healthcare providers gain insights and improve outcomes through quality measure benchmarking. Benchmarking allows us to identify best practices in care. By analyzing variation in quality measures, we can identify research opportunities that advance professional knowledge, which informs the creation of future best practices.¹ Similarly, quality measure benchmarks can be used to accurately track quality improvement progress.  

How does CMS use quality measurement and improvement?

CMS uses quality improvement and quality measurement to achieve the goals and priorities of the Meaningful Measures Framework. The purpose of the Framework is to improve outcomes for patients, their families and providers while also reducing burden on clinicians and providers. CMS’ areas of focus are:

• Addressing high impact measure areas that safeguard public health
• Adopting measures that are patient-centered and meaningful to patients
• Adopting outcome-based measures where possible
• Fulfilling legislative requirements
• Minimizing burden for providers
• Identifying significant opportunities for improvement
• Addressing measure needs for population-based payment through alternative payment models
• Aligning across programs and payers (e.g., Medicare, Medicaid, and commercial payers)

The mechanism of quality improvement is standardization. 

1. First, behavior is made systematic so that the same inputs result in the same outputs within the bounds of uncertainty (randomness).
2. Second, behavior is aligned with evidence on sound practices (e.g., guidelines and systematic reviews). The Plan-Do-Study-Act (PDSA) Cycle is a systematic series of steps to identify the patient, process or system characteristics associated with “non-standardized behavior”. Through each repetition of the PDSA Cycle, behavior becomes more systematic and more aligned.² Behavior is standardized through both structure and process. Structure might include things like technology (e.g., electronic health records), leadership, or culture. Process might include standard operating procedures, education, and training. Standardization of structure and process increases the likelihood of desired health outcomes.

The mechanisms of quality measurement are selection and choice. 

A quality measure is a tool for making “good decisions” defined as decisions that make it more likely to experience a good result and less likely to experience an adverse result that was not foreseen or was not understood. Patient and families use quality measures to select high-performing clinicians. Healthcare providers use quality measures to assess their own performance. Selection and choice decisions based on sound quality measures increase the likelihood of desired health outcomes.³

Additional Information

1. Califf, R. M., Peterson, E. D., Gibbons, R. J., Garson, A., Brindis, R. G., Beller, G. A., & Smith. S. C., (2002). Integrating quality into the cycle of therapeutic development. Journal of the American College of Cardiology, 40(11), 1895-901.
2. Langley, G. J., Moen, R., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
3. Berwick D. M., James, B., & Coye, M. J. (2003). Connections between quality measurement and improvement. Medical Care, 41(1), I30-I38. https://doi.org/10.1097/00005650-200301001-00004