A critical first step in addressing the nation’s serious health care safety and quality concerns is the establishment of valid and reliable measurement systems that can be used to assess the degree to which care processes are consistent with the clinical knowledge base and patients are achieving desired outcomes. Clinical quality measurement provides the essential foundation for both quality improvement and accountability.

Although the quality enhancement processes of the major government programs are moving in a reasonably consistent and appropriate direction, the current set of activities has not closed the quality gap and is unlikely to do so in the future unless changes are made. This is the case for a number of reasons:

  1. A lack of consistency in performance measurement requirements both across and within individual government programs. In Medicare and Medicaid performance measurement requirements are quite extensive for managed care plans and to a lesser degree for hospitals. On the other hand, performance measurement requirements are minimal or nonexistent for noninstitutional providers under fee-for-service arrangements, which still account for the majority of health care services. States have considerable latitude in the way they choose to define, implement, and enforce quality review in Medicaid and SCHIP programs; not surprisingly, the level and degree of external review activity vary widely among and within state programs.

  2. The absence of standardized performance measures, resulting in an unnecessary burden on providers and diminished usefulness of quality information. Although some government programs have undertaken efforts to adopt standardized measures, these represent isolated success stories. The majority of performance measurement activities being carried out by the major government health care programs are neither standardized nor evenly applied across the programs. For private-sector providers, who typically participate in more than one government health care program, such variability in measures results in an excessive administrative burden.

  3. The lack of a conceptual framework to guide the selection of performance measures, resulting in a patchwork of measurement projects. What generally appears to be missing is a clear conceptual framework with criteria that can guide the selection of individual measures to help maximize the health of the population being served.

  4. A lack of computerized clinical data. VHA and DOD have made noteworthy strides in establishing a clinical information infrastructure, and the ability of their programs to measure and improve quality through continuous feedback and the application of computerized decision sup-

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