NQF Report Offers Guidance on Reporting Measurement Systems

By John Palmer

With value-based healthcare models becoming more popular, it’s more important than ever for healthcare organizations to be able to measure the care they provide.

Measurements help serve many purposes, including quality improvement, pay for performance, accreditation, and public reporting.

Yet, for some reason, organizations still lack an overarching process for assessing how individual quality measures work together.

That’s about to change, thanks to a recent report from the Washington, D.C.–based patient safety advocate group National Quality Forum (NQF).

“This is how we drive the next generation of quality improvement,” said Shantanu Agrawal, MD, MPhil, NQF’s president and CEO. “If we want to empower patients and other healthcare users to make informed decisions, measure sets and measurement systems must ensure valid assessments of quality and reliable results. This report draws on our collective expertise to define the components of sets and systems that must be transparent and also proposes standardized approaches to assess their design. With clarity on evaluation and impact, we can work together to improve the quality of healthcare for all.”

Using feedback from patients, patient advocates, purchasers, public and private payers, clinicians, provider groups, measure developers and implementers, statisticians, and health services researchers, the group looked at how standard measures used in healthcare assessment can be combined in a system to improve health outcomes and drive high-value care.

Via existing standards for developing and selecting individual measures, NQF collaborated to establish a method of assessing how measures can best work together.

“Measure sets and measurement systems can improve patient safety by working together, providing more accurate measures, assessing multiple components, and painting a more complete picture of quality,” said Agrawal. “This is how we drive the next generation of quality improvement.”

The NQF effort tasked a panel of 25 diverse healthcare experts with the goal of ensuring that measure sets and measurement systems produce accurate and measurable impact.

The group’s July 2020 report, entitled Measure Sets and Measurement Systems: Multistakeholder Guidance for Design and Evaluation, builds upon the tradition of taking on emerging national health needs that demand comprehensive approaches across sectors.

Many of the measure reporting requirements are based on federal programs, private health insurance providers, and accreditation entities, said Agrawal. Examples of a measure set and how it would be utilized in a typical healthcare setting or environment include the following:

• The Medicaid Core Sets are measure sets reported at the state level.
• HEDIS^® measures are a set of measures reported by health plans that determine accreditation, compare health plan performance, and serve as a performance improvement tool.
• The CQMC core sets were developed through a public-private partnership to align measures, using a multistakeholder process across payers in their value-based contracts.
• Several regional collaboratives and states have also created measure sets in an effort to track and drive progress toward specific goals and/or to be used in payment and service delivery models.

Composite measures can also be thought of as measure sets, Agrawal said. For example, PSI-90 is considered a measure set as it combines multiple preventable hospital-related events associated with harmful outcomes and is used in several public reporting and pay-for-performance initiatives to compare hospital performance. It can assist hospitals in assessing, tracking, and improving the safety of inpatient care.

“There exists an opportunity in the healthcare quality measurement field for greater access to comprehensive, actionable, and scientifically sound data to compare healthcare quality,” according to the report.

“Understanding the importance of the relationship between observed performance outcomes and the design of measurement systems is essential to the evolution of healthcare quality measurement and value-based models.”

According to Agrawal, agreement on the terminology and differentiating factors between sets and systems required a lot of discussion by the expert panel. Even though the use of measure sets is increasing and measurement systems play prominent roles in the healthcare industry, there were not agreed-upon definitions for these concepts.

“This work can help the quality field unite around a common understanding, which is crucial to advancing set and system design and evaluation,” Agrawal said.

Another interesting point was that even though stakeholders generally agreed that cohesive measure sets (e.g., sets implemented as a whole) are desirable, most measure sets are apparently not treated this way.

“Quite often, providers or those establishing value-based models select which measures from the set they would prefer to use, which can lead to a lack of alignment and less ability to understand performance more broadly or to establish benchmarks,” noted Agrawal. “We have a lot of opportunity for greater alignment in the design of sets and systems and the measures that are used within them. We look forward to advancing the transparency, actionability, and stakeholder understanding of sets and systems as we continue this work.”

The proposed methodology builds on the use of individual measures to assess quality, safety, and person-centered care; emphasizes goals at the outset; ensures the set and system is sound and aligned; and engages diverse stakeholders in the discussion to make sure that measurement systems provide accurate data about quality of care.

NQF intends to field test the approaches with developers and stakeholders to ensure that the guidance can be used to design valid assessments and produce better outcomes.

“Serving all patients with quality care is even more essential as our healthcare system contends with complex challenges, such as COVID-19 and its lasting impact,” said Agrawal. “We are indebted to our members, partners, and Technical Expert Panel for supporting this work and for demonstrating yet again that NQF is the forum for tackling emerging national health needs that demand comprehensive approaches across sectors.”

But how to get leadership buy-in to develop some of the recommendations from the report? Adopting measure systems throughout a healthcare facility must be a systematic process.

“Getting commitments and declarations of a shared vision from a facility’s leadership team is key in developing recommendations for aligning and improving systems,” Agrawal said.

Facilities should start small, commit to implementing something simple and doable, and be strategic about how new measure systems would fit in with existing quality measurement programs, he added. They should spur on teams already excited about quality improvement, or partner with groups that have demonstrated success to adopt measurement systems.

“Leaders should understand what measures are already in use and what available sources of data can be leveraged to build a culture of innovation to improve patient safety,” Agrawal said. “We are taking similar steps internally at NQF. We are evaluating changes to our core programs, such as endorsement, to better integrate this thinking and work.”

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.