Measuring Quality

The National Quality Measures Clearinghouse identifies 2,100 quality indicators, and the Agency for Healthcare Research and Quality (AHRQ) National Healthcare Quality and Disparities Report contains more than 250 indicators. Avedis Donabedian, a pioneer in the study of quality in health care, established the important linkage between structure and process in affecting any outcomes of interest. This concept is still important today and is summarized below.

Structural measures. These metrics look at the attributes of a health care provider organization that would promote quality of care. Examples of these include the physical location, the number of staff members, and the use of databases and registries. The primary focus of structural measures is on the organization as opposed to the patient.1

Process measures. These metrics look at the process of care for the patient. They represent the things that are actually “done to and with the patient.” They are rather common and include ordering lab tests (e.g., A1C, blood pressure, and LDL cholesterol tests), conducting eye exams, and measuring body mass index.

Outcome measures. These metrics look at the health state of a patient resulting from health care. An outcome measure thus requires data about health states (i.e., states occurring within the body of a patient).1 Mortality and morbidity are classic outcome measure endpoints. Actual lab values, such as an A1C that is less than 7 percent, are intermediate values that are known to impact morbidity and mortality. Outcomes can be viewed in aggregate in disease models to measure long-term outcomes as a surrogate for actual population metrics. The common health risk assessment provides patients with graded opportunities to improve health through risk reduction.1

Patient-reported outcome measures (PROMs). There is increasing interest in PROMs to improve the quality of health care.2 PROMs are any reports coming directly from patients about their health condition and treatment,3 including symptoms, functional status, and health-related quality of life.4 Recent systematic reviews have demonstrated that PROMs can improve patient-clinician communication and the processes of care for individual patients, but they have also consistently shown minimal influence on patient outcomes.2 Research into the use of PROMs as quality improvement tools is ongoing and may increasingly guide health care systems in how they approach quality.

Other measures have been developed recently and play an important part in the measurement of quality in health care, including

  • Value measures. Value is often defined with the equation quality of a product over cost (Q/C). The perceived quality of care allows the consumer to spend more money for the product. In health care, metrics that assess value are used to determine if the care provided advances the actual health of the patient receiving that care (it is deemed “effective”—and if so—at what cost). Care that is “high value” has highly “effective” quality at lower cost. The current discussion of the Triple Aim5 has an inherent measure of value.
  • Patient satisfaction/Patient experience measures. These measures are often gathered through a standard questionnaire but may also be gathered through other means of patient feedback. The two most common survey tools are the Consumer Assessment of Healthcare Providers and Systems (CAHPS)6,7 and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).8 As is common in other industries, a measure of patient—or consumer—feedback drives an organization to improve the quality of its services.

HEDIS measures. Outpatient diabetes performance measures have been incorporated into the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures; these are reported publicly for Medicare, Medicaid, and commercial and managed care plans that serve Medicare beneficiaries. Many health plans report HEDIS data to employers or use their results to make improvements in their quality of care and service. Employers, consultants, and consumers use HEDIS data, along with accreditation information, to help them select the best health plan for their needs.

Diabetes HEDIS measures for care, screening, or testing needed for comprehensive diabetes care for adults ages 18 to 75 consist of some of the following9

  • A1C testing twice a year
  • A1C result > 9% = poor control
  • A1C < 8% = control
  • retinal eye exam
  • nephropathy screening test or evidence of nephropathy
  • blood pressure < 140/90

Quality Payment Program. The Centers for Medicare and Medicaid Services (CMS) has named the new clinician payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as the “Quality Payment Program.” The primary goal of the program is to reward clinicians for quality patient outcomes, rather than paying for the volume of services provided. Regardless of whether a clinician participates in MACRA through the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (Advanced APM), clinicians will be assessed on the quality of care provided. HEDIS measures and MACRA quality measures are relatively similar—however, some differences exist between the two.

Accountable Care Organizations (ACOs). ACOs are an example of an Advanced Payment Model. ACOs are held accountable for the quality and total “spend” for the population they care for. Within the ACO construct, patients with diabetes represent a significant opportunity for care coordination activities that will translate into reduction in total spend for diabetes-related care. Although not usually considered as “quality measures,” forward-thinking systems are beginning to consider tracking and managing measures such as rate of admissions/1,000 patients and rate of emergency room visits/1,000 patients. This is reflected in newer types of quality measures such as Risk-Standardized Acute Admission Rates for Patients With Diabetes (PDF, 742 KB).

As noted above, the list of MACRA quality measures will continue to be expanded over time. The current measures can be found on the official Quality Payment Program website. The initial Priorities for Measure Development by Quality Domain include10

Clinical Care

  • Measures incorporating patient preferences and shared decision-making
  • Cross-cutting measures that may apply to more than one specialty
  • Focused measures for specialties that have clear gaps
  • Outcome measures


  • Measures of diagnostic accuracy
  • Medication safety related to important drug classes

Care Coordination

  • Assessing team-based care (e.g., timely exchange of clinical information)
  • Effective use of new technologies, such as telehealth

Patient and Caregiver Experience

  • PROMs
  • Additional topics that are important to patients and families/caregivers (e.g., knowledge, skill, and confidence for self-management)

Population Health and Prevention

  • Developing or adapting outcome measures at a population level, such as a community or other identified population, to assess the effectiveness of the health promotion and preventive services delivered by professionals
  • Institute of Medicine Vital Signs topics (e.g., life expectancy, well-being, addictive behavior)
  • Detection or prevention of chronic disease (e.g., chronic kidney disease)

Affordable Care

  • Overuse measures (e.g., overuse of clinical tests/procedures)