measurement and monitoring systems that include both population-level measures and measures at the level of the health care delivery system. Also, as discussed in Chapter 5, rural communities incorporating pay-for-performance programs or alternative payment models into a demonstration project may well choose to tie payment incentives to the achievement of population and personal health goals.

Efforts are already under way to identify and adapt leading measure sets for application in rural provider sites (Casey and Moscovice, 2004). In particular, the American Hospital Association is currently developing a rural version of the measure sets for myocardial infarction, heart failure, and pneumonia that are used in the National Voluntary Hospital Reporting Initiative (Personal communication, N. Foster, July 9, 2004). For example, since rural hospitals stabilize and transfer patients more frequently than do urban hospitals, the discharge measures need to be adjusted to better reflect and ensure quality of care in patient transfers.

Performance Measurement and Data Feedback Capabilities

Local health systems must have performance measurement systems capable of monitoring progress across a well-balanced set of standardized performance measures and providing timely feedback to administrative and clinical staff (e.g., comparative reports). At present, most performance measurement and improvement activities rely on data abstracted from paper medical records, culled from administrative datasets, or in some cases maintained in disease registries. While these have historically been the most important data sources and should be fully exploited by quality improvement programs, they have serious limitations. Administrative files and registries lack the comprehensive and clinically rich data necessary to address many important aspects of performance and to adjust for differences such as severity of illness. Abstraction of paper medical records is a slow and resource-intensive process. The same ICT infrastructure (see Chapter 6) that is needed to provide real-time computer-aided decision support to providers can support the performance measurement monitoring process.

Quality Improvement Processes and Resources

Well-thought-out quality improvement processes with adequate human and technical resources are essential to accomplishing the six quality aims.

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