Purpose/aims—No coherent approach to specifying purposes and aims of measurement.

Specify a clear national purpose for the health care system and explicit aims for improvement.

Measures—Limited scope of measurement (failure to measure in many domains) and a multiplicity of competing measures in some domains. Lack of clarity and uniformity prevents information technology vendors from planning to include measures.

Establish a national system of standardized performance measures that are linked to aims, comprehensive in scope, and aligned with current and expected capabilities for reporting.

Data aggregation/reporting—Lack of standardization, multiple conflicting stakeholders collecting data independently, unjustifiable reporting burden on providers, and reporting that often confuses consumers.

Ensure well-developed data collection and aggregation processes to minimize the burden on providers while ensuring efficient measurement across payers and providers. Develop public reports that are valid, understandable, and actionable.

Funding—Inadequate and unstable funding for performance measurement activities and research.

Sustain adequate funding for a structure able to withstand pressures of stakeholder interests and keep patients’ needs in the foreground.

Capacity to learn—Efforts to improve quality constrained by a lack of evidence on the effectiveness of alternative improvement strategies, potential adverse effects of measurement, best ways to communicate quality information to providers and consumers, and effectiveness of pay-for-performance initiatives.

Evaluate the effectiveness of performance measurement, public reporting, and payment systems and quality improvement initiatives to minimize potential adverse effects, detect unintended consequences, and maximize the eventual benefits of performance measurement.