Quality of Care

Defining key terms:
Quality of Care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. High quality care means that providers follow current best medical evidence and prioritize decisions that are consistent with peoples’ values, needs, and preferences for a positive patient experience. Health Equity: The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. (Source: CMS)

Defining key terms:

Quality of Care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. High quality care means that providers follow current best medical evidence and prioritize decisions that are consistent with peoples’ values, needs, and preferences for a positive patient experience.
Health Equity: The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. (Source: CMS)

Quality of Care Applied

A major aim of CMS Innovation Center pilots (models) is to improve quality of care for patients. Quality of care is defined by how well the care achieves desired health outcomes and contributes to a positive patient experience. Some examples of quality that might be evaluated in a model are:
Improving how doctors help patients manage their blood pressure or diabetes, or making sure patients receive timely screening tests like colonoscopies
Reducing the likelihood a patient needing to return to the hospital due to complications from a surgery
Increasing a person’s ability to remain safely in their home while receiving treatment, for instance infusion of a medication or home dialysis
Improving providers’ coordination during care transitions, for instance making sure patients have all required medications when going home, or to a rehabilitation facility, from the hospital
Referring patients to resources to help them get food or transportation or their lights turned back on, if these needs are identified in health-related social needs assessments

Measuring Quality of Care

To evaluate quality of care, CMS Innovation Center models might look at:

Processes of care, for example, checking blood pressure and prescribing treatment to address high blood pressure, or screening for depression and referring patients in need to a behavioral health specialist
Care outcomes, for example a person’s ability to climb stairs after a hip replacement, blood pressure being under control, or avoiding complications after surgery
Key characteristics of a provider’s practice, such as the ratio of nurses to staff, or the use of a certified Electronic Health Record (EHR)

Quality of care is measured using different types of data, including information submitted by providers through administrative billing records, reported by patients (such as through surveys), and made available through EHRs. Increasingly, the CMS Innovation Center is including patient reports of their experience with health care providers when evaluating quality of care.

Patient Experience and Outcomes: An Example of Quality of Care

CMS Innovation Center kidney care pilots include quality measures that assess both outcomes of care, for instance how frequently patients require avoidable hospitalizations and patient experience.

When Letisha learned she needed kidney dialysis, where a machine removes waste products from the blood when the kidneys stop working, she worried about how it would impact her life. She recalled her mother’s experience having to wake up in the wee hours of the morning three times a week to get to a dialysis center many miles from their home. But working with her doctor who takes part in a CMS Innovation Center pilot program, Letisha receives dialysis from the comfort of her home. She eats dinner, watches TV, and plays Scrabble with her family while getting dialysis. She can also continue working. As a result, she experiences less disruption to her life and more positive health outcomes from the treatment.

Letisha’s medical outcomes, like whether she needs to go to the hospital, may be the same as if she did her dialysis at a facility, but her experience of care - and her quality of life - are much better when she can get her dialysis at home. This is why outcomes and experiences must both be considered to get a full picture of the quality of care. Read more about Letisha’s story.

Quality of Care and Health Equity

Measuring quality of care contributes to health equity efforts by identifying which populations do not receive the care they need or receive care that is lower quality. It also shows how quality differs across providers. By standardizing quality measurements, CMS makes it easier to compare providers and patient populations. These comparisons help identify and eliminate disparities (preventable differences) in health outcomes.

Additional Information

To learn more about Quality of Care, visit our Blogs and Publications page.