What Are Clinical Quality Measures?
Clinical quality measures, often abbreviated CQMs, are tools used to quantify healthcare processes, outcomes, patient perceptions, and organizational structures associated with the ability to provide high-quality care. These measures allow organizations, payers, and regulators to evaluate and compare performance.
Donabedian's Framework
Avedis Donabedian's classic framework categorizes quality measures into three types: structure, process, and outcome.
Structure Measures
Structure measures assess the attributes of the settings in which care occurs, such as staffing ratios, availability of certain equipment, or accreditation status. Structure measures are indirect indicators of quality since they describe capacity for good care rather than actual care delivered.
Process Measures
Process measures assess whether specific evidence-based actions were performed during the delivery of care, such as whether a patient with pneumonia received antibiotics within a recommended timeframe. Process measures are useful because they are directly actionable and closely tied to clinical guidelines.
Outcome Measures
Outcome measures assess the results of care, such as mortality rates, complication rates, or patient-reported functional status. Outcome measures are often considered the ultimate indicator of quality but can be influenced by factors outside a provider's control, requiring risk adjustment for fair comparison.
National Quality Forum
The National Quality Forum, known as NQF, is a nonprofit organization that reviews and endorses standardized quality measures for use in national reporting programs. NQF endorsement indicates that a measure has been rigorously evaluated for scientific soundness, feasibility, and usability.
CMS Quality Programs
The Centers for Medicare and Medicaid Services operates several quality reporting and value-based purchasing programs that rely on standardized quality measures, including the Hospital Inpatient Quality Reporting Program, the Hospital Readmissions Reduction Program, and the Merit-based Incentive Payment System for eligible clinicians. Facilities that fail to meet reporting requirements or perform poorly on selected measures may face payment penalties.
The Role of HIM in Quality Measurement
- Ensuring documentation supports accurate quality measure abstraction
- Extracting and validating data used in quality reporting submissions
- Collaborating with quality departments on measure specification changes
- Supporting risk adjustment coding accuracy for outcome measures
Conclusion
Understanding the structure, process, and outcome framework, along with national quality reporting requirements, equips HIM professionals to support accurate and meaningful quality measurement across their organizations.