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Quality Measure and Quality Improvement

Quality Measure and Quality Improvement

The vision of the CMS Quality Strategy is to optimize health outcomes by improving quality and transforming the health care system [1].   CMS serves the public as a trusted partner with steadfast focus on improving outcomes, beneficiary/consumer experience of care, population health, and reducing health care costs through improvement. Among the areas of focus are:

  • Leading quality measurement alignment, prioritization, and implementation and the development of new, innovative measures;
  • Guiding quality improvement across the nation and fostering learning networks that generate results.

The close connection between quality measurement and quality improvement is also evident in the Merit-based Incentive Payment System (MIPS) in which participants earn performance-based payment adjustments based on evidence-based and practice-specific data in the categories of quality, improvement activities, advancing care information, and cost (starting in 2018) [2].

What is quality measurement and quality improvement, and how exactly are quality measurement and quality improvement connected? The starting point is the definition of quality from the National Academy of Medicine: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge [3].   Both quality measurement and quality improvement increase the likelihood of desired health outcomes, using different but mutually supporting mechanisms.

The mechanism of quality improvement is standardization.   First, behavior is made systematic so that the same inputs result in the same outputs within the bounds of uncertainty (randomness).   Second, behavior is aligned with evidence on sound practices (e.g. guidelines and systematic reviews).   The PDSA Cycle (Plan-Do-Study-Act) 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 [4]. We standardize behavior through both structure and process.   Structure might include things like physical capital (EHR), leadership or culture.   Process might include knowledge capital (standard operating procedures) or human capital (education and training).   Standardization of structure and process increases the likelihood of desired health outcomes.

The mechanisms of quality measurement are selection and choice [5]. A quality measure is used as 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. Consumers use quality measures to select high performing clinicians, and low performing clinicians choose to allocate resources to become high performing.   Selection and choice decisions based on sound quality measures increase the likelihood of desired health outcomes.

How are quality measurement and quality improvement mutually supportive? Through benchmarking of quality measures – which means using comparison groups of peers with similar patients, process, and system characteristics to identify “sound practices” that may be implemented in quality improvement – providers use quality measures to improve outcomes. Analysis of variation in quality measures may suggest concepts for future biomedical, clinical, or health services research that may contribute to the advancement of professional knowledge through the identification of new “sound practices” [6].

Quality improvement tends to be about learning, culture change, and capacity building.   Often the focus is on features that are unique or idiosyncratic to each organization and context. The goal of quality improvement is to the degree possible to transform such unique and idiosyncratic features through the development of physical, knowledge or human capital or the standardization of process. However because quality improvement is often so organization and context dependent, there is an entire body of knowledge called implementation science that is the study of methods that influence the integration of evidence-based interventions into specific practice settings.        

Both quality improvement and quality measurement are necessary to achieve the goals and priorities of the CMS Quality Strategy.





[3] Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy, 2001. Print.

[4] Langley, Gerald J. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass, 2009. Print.

[5] Berwick DM, James B, Coye MJ, Connections between quality measurement and improvement, Med Care, 2003;41(1 Suppl): I30-I38.n. New York: Duxbury, 2004

[6] Califf, Robert M., Eric D. Peterson, Raymond J. Gibbons, Arthur Garson, Ralph G. Brindis, George A. Beller, and Sidney C. Smith. "Integrating Quality into the Cycle of Therapeutic Development." Journal of the American College of Cardiology 40.11 (2002): 1895-901. Web.