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What is a Quality Measure

What is a Quality Measure?

Quality measures, which can also be referred to as Clinical Quality Measures (CQMs) and electronic Clinical Quality Measures (eCQMs), are tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.

Measurement is a step in improving health care quality, and quality measures help drive that improvement through a consistent and accountable approach While each measure focuses on a different aspect of health care delivery, together they provide a more comprehensive picture of the quality of healthcare. CQMs and eCQMs measure many aspects of patient care including:

  • Health outcomes
  • Clinical processes
  • Patient safety
  • Efficient use of health care resources
  • Care coordination
  • Patient engagements
  • Population and public health
  • Adherence to clinical guidelines

A measure is made up of several components. It has a title and description of what it is. It must also have a numerator, denominator, and denominator exclusions. The numerator, which is also called the measure focus, describes the target process, condition, event, or outcome expected for the targeted population. The denominator defines the population being measured—it could be the whole population or a subset. The denominator exclusion identifies members of this population who should be removed from the measure population, and hence the denominator, before determining if numerator criteria are met. Below is an example of a measure and what those components look like and mean:

Measure Title: Controlling High Blood Pressure

Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

Numerator: The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.

Denominator: Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.

Denominator Exclusions: Exclude all patients with evidence of end-stage renal disease (ESRD) on or prior to the end of the measurement year. Documentation in the medical record must include a related note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets the criteria for evidence of ESRD. Exclude all patients with a diagnosis of pregnancy during the measurement year. Exclude all patients who had an admission to a nonacute inpatient setting during the measurement year.

This measure is focused on patients between the ages of 18-85 who have a diagnosis of hypertension during an outpatient encounter and whose blood pressure was adequately controlled, < 140/90 mmHg, during the measurement period. Excluded from this patient population is 1) anyone with documented evidence of end-stage renal disease (ESRD), 2) anyone with a diagnosis of pregnancy during the measurement period, and 3) anyone admitted to a nonacute inpatient setting during the measurement period. The measure is designed to promote the most effective prevention and treatment practices.