Appendix D
Ten Design Principles

Principle 1: Comprehensive Measurement

A performance measurement system should advance the core purpose of the health care system and foster improvements in all six quality aims identified in the Quality Chasm report (IOM, 2001): safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The committee endorses the following statement of purpose, proposed by the President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry:

The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.

Principle 2: Evidence-Based Goals and Measures

A performance measurement system should be guided by a comprehensive set of evidence-based goals for improvement, where appropriate. The National Quality Coordination Board (NQCB) should identify explicit health care goals for the nation, assess progress toward achieving these goals; and continually update and modify the goals as circumstances, information, and needs change. As a starting point, the NQCB should adopt the priority areas for quality improvement identified by the Institute of Medicine (IOM, 2003), as endorsed and expanded by the National Quality Forum (2004), as national goals, and specify measures corresponding to



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Performance Measurement: Accelerating Improvement Appendix D Ten Design Principles Principle 1: Comprehensive Measurement A performance measurement system should advance the core purpose of the health care system and foster improvements in all six quality aims identified in the Quality Chasm report (IOM, 2001): safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The committee endorses the following statement of purpose, proposed by the President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry: The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States. Principle 2: Evidence-Based Goals and Measures A performance measurement system should be guided by a comprehensive set of evidence-based goals for improvement, where appropriate. The National Quality Coordination Board (NQCB) should identify explicit health care goals for the nation, assess progress toward achieving these goals; and continually update and modify the goals as circumstances, information, and needs change. As a starting point, the NQCB should adopt the priority areas for quality improvement identified by the Institute of Medicine (IOM, 2003), as endorsed and expanded by the National Quality Forum (2004), as national goals, and specify measures corresponding to

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Performance Measurement: Accelerating Improvement these goals that encompass the care of patients across the lifespan (e.g., staying healthy, getting better, living with chronic illness, and coping with end of life) (FACCT, 1997). Principle 3: Longitudinal Measurement Standardized performance measures should characterize health and health care of a patient both within and across settings and over time. The NQCB should identify standardized measures that characterize the health and quality of care received by both individuals and populations. In general, the measures should not vary by type of health care provider or setting, but should characterize care across as well as within sites and settings. The set of standardized measures should provide the information needed to assess progress toward achieving the six quality aims and the national goals. Principle 4: Supportive of Multiple Uses and Stakeholders A national system for performance measurement and reporting should provide information for multiple uses, including provider-led improvement efforts, public reporting, payment and benefits design, and population health initiatives. This system should produce useful information for three purposes: Accountability—Information should be available to assist stakeholders in making choices about providers, including patients identifying a clinician, hospital, or other provider from which to seek services; purchasers and health plans selecting providers to include in their health insurance networks; and quality oversight organizations making accreditation and certification decisions. Quality improvement—The information provided should be of value to stakeholders responsible for improving the quality of care, including clinicians and administrators and governing board members of health care organizations. Population health—The information should be useful for stakeholders making decisions about access to services (e.g., public insurance benefits and coverage); those involved in communitywide programs and efforts to address racial and ethnic disparities and promote healthy behaviors; and public officials responsible for disease surveillance and health protection. Principle 5: Measurement Intrinsic to Care Performance measurement should be intrinsic to the care process. For most standardized measures (e.g., health care processes and some outcome

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Performance Measurement: Accelerating Improvement measures), the data generated to calculate measures should be byproducts of the patient care process and should reside within an electronic health record system. For example, the data required to calculate standardized measures for assessing the quality of patient care provided to diabetics (e.g., cholesterol and hemoglobin A1c levels) should be captured as a part of patient care encounters. This approach has several advantages: (1) it allows for the development of computerized decision-support systems (e.g., prompts to providers and patients that the patient is due for an annual retinal exam); (2) it enables more immediate calculation of measures and feedback to providers on performance; and (3) it minimizes the burden associated with special data collection processes. These data reflect the health care delivery system; in and of themselves they do not adequately address population and public health. Principle 6: A Central Role for the Patient’s Voice The performance measurement system should also include direct reports and ratings from patients and family caregivers. Patients need a voice in the process of selecting measures and designing public reports. The input of patients and family caregivers should reflect their viewpoints on the quality and functionality of the care received. Caregivers’ perceptions of the quality of care provided should also be incorporated into the measurement system. Principle 7: Individual-, Population-, and Systems-Based Measurement Measurement and measures should assess the health and health care of both individuals and populations and the many systems within which care is provided. A national system for performance measurement and reporting should include both measures of the quality of care provided by the personal health care system and measures of population health, health behaviors, and unmet health needs. The measure set should include measures of access and unmet service needs for the entire population of a community and for specific groups most likely to experience access limitations because of an inability to pay; high levels of uninsurance or underinsurance; racial, ethnic, class, cultural, and linguistic barriers; or geographic impediments. The measure set should also include measures of the efficiency of the local health system, such as resource use compared with that of other communities. Principle 8: Shared Accountability Measurement should not be constrained by the absence of a current, identifiable, single responsible agent. A national system should measure pro-

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Performance Measurement: Accelerating Improvement cesses and outcomes of care important to patients and communities. Measurement should foster individual and shared accountability for health system performance. When no responsible agent can be identified, shared accountability by all agents within the health care system should be presumed, and responsible stewardship encouraged and induced. In many settings, this will require significant restructuring of how care is currently delivered. Principle 9: A Learning System A performance measurement system should be a learning system, continually evaluating its own performance and advancing knowledge regarding performance measurement. A national system for performance measurement and reporting should advance knowledge of (1) how environmental levers, such as purchasing, pay for performance, and quality oversight can best be used to motivate quality improvement; (2) the most effective strategies for redesigning care processes, including methods for transferring knowledge, implementing information technology, and forming effective care teams; and (3) the extent to which all quality efforts lead to improvements in the six quality aims. Principle 10: Independent and Sustainable A performance measurement and reporting system should be continually enhanced and financed in a way that ensures its independence and sustainability. This system should be dynamic and should evolve based on careful evaluation of its impact and advances in the science base. It should be adequately supported by both public- and private-sector stakeholders. REFERENCES FACCT (Foundation for Accountability). 1997. The FACCT Consumer Information Framework: Comparative Information for Better Health Care Decisions. [Online]. Available: http://www.facct.org/information.html [accessed June 4, 2002]. IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. IOM. 2003. Priority Areas for National Action: Transforming Health Care Quality. Adams K, Corrigan JM, eds. Washington, DC: The National Academies Press. National Quality Forum. 2004. National Priorities for Healthcare Quality Measurement and Reporting. [Online]. Available: http://www.qualityforum.org/webprioritiespublic.pdf [accessed January 19, 2005].