The committee approached the challenge of selecting a starter set of performance measures by first identifying the analytic frameworks for quality assessment that have guided the development of measures in the past. The most important of these were the six aims set forth in the Quality Chasm report (IOM, 2001) and the Foundation for Accountability’s call for assessing care across the lifespan (FACCT, 1997). The committee then identified leading performance measures and measure sets, classifying them within the existing analytic frameworks. A full description of the selection and classification methodology can be found in Appendix E.

The committee recognizes limitations to this approach, as the primary emphasis was on measurement of health care services. This focus constrained the committee’s ability to include measures of other important areas that have a profound impact on health outcomes, such as health behaviors and disparities in care. The committee also acknowledges the difficulty of adopting these measures, particularly for certain providers. For example, rural hospitals will face different barriers to implementation from those faced by community-based hospitals or academic health centers. The committee’s approach did, however, make it possible to identify the major gaps in current performance measure sets and to specify the 10 design principles for a performance measurement and reporting system set forth in Chapter 2. These 10 design principles, in turn, provided an additional lens for the classification of current measures, as well as a basis for recommending next steps.


The committee reviewed more than 800 measures within the analytic frameworks noted above. As a result of this effort, the committee identified several major gaps in existing measure sets, summarized in Table 4-1. The following sections highlight those areas in which the committee proposes significant changes in direction or new emphasis in performance measurement, as embodied in the following approaches:

  • Comprehensive measurement

  • Longitudinal measurement

  • Individual patient-level, population-based, and systems-level measurement

  • Shared accountability

These approaches represent a change relative to current performance measurement efforts as they provide different frameworks through which

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