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A clear plan for using quality measurement is a prerequisite to a successful quality measurement strategy. An established plan helps ensure that decisions are made with the project purpose in mind.

This section:

• Describes the major uses of quality measurement.
• Identifies questions to help assess possible uses.
• Lists key quality measurement reporting issues.

Uses of quality measurement include:

Program Management. Overseeing key functions to ensure that program goals are met and resources are used efficiently.

Accountability. Demonstrating achievement of identified goals.

Quality Improvement. Devising and tracking the impact of targeted interventions designed to improve health services.

Reporting Results. Reporting to a variety of stakeholders and other audiences.

Program Management

Regular measurement of quality is an important program management tool because it:

• Promotes the effective use of scarce resources and delivery of needed services.
• Provides information needed to manage health plans, providers, and other vendors and contractors.
• Provides a basis for offering incentives to these parties.
• Allows comparison of plan or program performance with that of other plans or programs in the State or in other States.
• Allows the tracking of trends over time.
• Provides an objective basis for ongoing quality improvement programs.
• Facilitates customized reporting to multiple constituencies.

The Federal Balanced Budget Act of 1997 mandated increased attention to performance monitoring as a tool for ensuring the delivery of quality services in Medicaid and the State Children's Health Insurance Program (SCHIP).

Online Resource: Review excerpts from the Federal Balance Budget Act of 1997.

In response to this requirement, the Centers for Medicare & Medicaid Services (CMS) formed the Performance Measurement Partnership Project (PMPP) to select a common set of measures that can be used by Medicaid and SCHIP programs to assess the quality of care. Final recommendations of the PMPP, which is composed of State and Federal officials, are expected in 2004.

The development of mandatory Title V performance measures by the Health Resources and Services Administration's Maternal and Child Health Bureau and the development of Medicaid performance measures by CMS in response to the mandates of the 1993 Federal Government Performance and Results Act (GPRA) have also brought increased attention to program performance issues.

Online Resources:

• Information on Title V performance measures.
• .

Strategy Development Questions

As you develop your program management strategy, here are some questions to consider:

• How do you monitor health plans, providers, and outside vendors and contractors? Could quality measurement help you hold them accountable?
• How do you enforce contractual requirements? Could quality measurement provide you with better information?
• How do you learn whether your program is accomplishing its intended goals? How do you know whether the decisions you make have their intended impact?
• How do you build staff expertise in quality oversight and monitoring? Could a quality measurement initiative help create and reward performance-oriented staff expertise?

Resources for Program Management

You may wish to explore ´óÏóÊÓƵprogram management tools:

• AHRQ's evidence reports and technology assessments review the relevant scientific literature on certain clinical care topics for others to use as a basis for clinical guidelines and other quality improvement activities. Some of these topics relate to child health issues. These resources are also useful for quality improvement.

  Online Resource:

• List of AHRQ's evidence report topics.
• Information on these ´óÏóÊÓƵProgram Management Tools.

Accountability

Accountability in publicly funded health care programs is a top priority. The use of quality measurement allows program managers to:

• Hold health care plans and providers responsible for the services they furnish.
• Assess the extent of their own accomplishments.

Example: Both providers and program managers may be held accountable for seeing that children are receiving the appropriate number of well-child visits or that children with special health care needs receive timely care.

Those in the legislative and executive branches can also use quality measurement information to:

• Assess the strengths and weaknesses of a program.
• Identify whether the decisions they have made are having the intended results.

When developing a quality measurement strategy, consultation with all stakeholders can help identify areas of interest.

Strategy Development Questions

As you consider using quality measurement for accountability, some questions to assess include:

• Who are your stakeholders? What are their needs and expectations? Do they expect quality measurement reports? Could quality measurement reports provide them with valuable information?
• What goals have your legislative and executive officials established for your program? Could quality measurement information help them assess whether these goals are being met?
• What are the requirements of your funders? Do they require quality measurement reports? Could quality measurement reports provide them with valuable information?

Quality Improvement

Quality measurement provides one of the tools needed for effective quality improvement initiatives. You can use quality measurement to establish the initial or baseline level of performance and to remeasure performance after the quality improvement intervention has begun.

Example: You can measure the current baseline rate of adolescent immunization, the hospitalization rate for children with asthma, or parental satisfaction with wait times in doctors' offices. You can then use the same performance measurement tool to remeasure that same indicator after the quality improvement intervention has been put in place and get a before-and-after comparison of the results, such as:

• Have adolescent immunization rates improved?
• Has the hospitalization rate declined?
• Has satisfaction with wait times increased?

Without using quality measurement to assess the situation both before and after the changes designed to improve performance, it is impossible to determine whether quality is indeed improving or by how much.

Strategy Development Questions

As you consider using quality measurement for quality improvement, some questions to assess include:

• Have you and your stakeholders prioritized child health quality improvement issues? Do you want to improve preventive care? Target a particular health condition such as pediatric asthma?
• Have you reviewed data sources that you already have on hand? Have you looked at systematic surveys or prior reports for indications of quality problems? Have you reviewed consumer or advocate complaints and records of grievances or appeals to identify potential problems? Have you reviewed recent reports from professional associations? From other States?
• Do you serve identifiable subgroups with likely child health quality issues? Children in immigrant families? Children with special healthcare needs? Identifiable racial or ethnic groups with potential health care disparities?
• Does your State have particular environmental or other circumstances that are likely to be connected with health problems that could be addressed by health care providers? High lead paint or other likely lead exposures? Hazardous waste sites?

Quality Improvement Tools

Online Resource: AHRQ's website, QualityTools, provides links to strategies and tools for quality improvement strategies.

Reporting Results

Quality measurement information is frequently reported to stakeholder groups and other audiences. Such information can be complex. To ensure that quality measurement reporting projects achieve their intended results, careful planning is required. Some issues to include in such planning are:

• Know Your Audience
• Consider a Pilot Year
• Involve Your Stakeholders
• Consider Focus Groups
• Plan Your Dissemination Strategy

Know Your Audience

There are a variety of potential audiences for quality measurement reports, including:

• Legislators.
• State officials.
• Providers.
• Health plans.
• Advocates.
• Consumers.

Each audience has its own:

• Characteristics.
• Needs.
• Potential uses for the information.

Thorough knowledge of your intended audience is essential as you design quality measurement reports. Note that designing a single report for multiple audiences can result in a report that suits no one.

Example: A given report may be too detailed for consumers but overly simplified for health plan representatives.

Design issues needing careful attention include:

Vocabulary. What vocabulary does the intended audience use on a regular basis? Presenting your results in words that are familiar to that audience is essential.

Interests. What does the intended audience want to know? What questions need to be answered? To get attention, results must respond to audience interests.

Likely Uses. What types of information does your intended audience need? What will they do with the information? Do they need it for decisionmaking or to carry out their responsibilities? Would they use it for individual decisionmaking?

Format and Graphic Presentation. What will engage your audiences? What are they used to? Different audiences are accustomed to differing amounts and kinds of information. Some audiences will easily review dense, multipage texts. Others get most of their information from electronic media and will respond more readily to interesting graphics and colorful presentations.

Online Resource: TalkingQuality is a resource on the latest research findings, real-world examples, and innovative ideas on ways to communicate complex information on health care quality to consumers. Developed by a work group of researchers with expertise in quality reporting, the Web site provides sponsors of quality reporting projects with reference materials and current evidence on what works best with consumers.

Consider a Pilot Year

Collection and reporting of quality measures take:

• Time.
• Effort.
• Resources.
• Practice.

First-time quality measurement results typically reflect the process of learning about the unexpected and dealing with the unanticipated. Many quality measurement practitioners recommend that the first year be defined as a pilot year, without public release of measurement results. The advantages of having a pilot year include:

• Second-year results are more likely than first-year results to reflect actual performance and will better serve the audience receiving the reports.
• Providers or plans welcome the opportunity for a practice year without adverse consequences.

Although public information requirements govern many situations, some users have found that a clear statement of the purpose of a pilot year has resulted in general willingness to wait for public results until the second round of data collection is complete.

Involve Your Stakeholders

At the very beginning of your work, consider creating an advisory group composed of stakeholders that includes:

• Health plans.
• Providers.
• Consumers.
• Advocates.

Having such an advisory group:

• Allows you to keep them informed.
• Allows you to get their input on a timely basis.
• Allows them to voice their fears and hopes.
• Allows them to develop an interest in the success of the project.
• Provides input that enables timely course corrections and helps avoid mistakes.

Airing plan/provider and consumer/advocate concerns in the same setting can create:

• Mutual understandings.
• Realistic expectations.
• A common core of knowledge about performance measurement reporting.

When reports are released, knowledgeable stakeholders can help explain their significance to the public.

Consider Focus Groups

A stakeholders' advisory group can function as an informal focus group. However, use of formal focus groups drawn from your target audience(s) as you develop your project plan can:

• Provide additional and invaluable information about what group members will find of interest.
• Indicate the best ways to communicate this information effectively.

If resources allow, using professional assistance in designing and administering the focus group(s) can yield insights that will significantly increase the effectiveness of the end report.

Plan Your Dissemination Strategy

Clichés about excellent reports gathering dust apply to quality measurement reports as well. A well-planned dissemination strategy needs to be a part of every performance reporting plan, and it should be developed early in the process. Answers to these questions should be included:

• For what audience(s) is this report intended? Where do they get their information?
• What other stakeholders or audiences should also get this information? How do they get their information?
• Do you want media coverage? If so, how can you get media attention? If not, what will you say when you receive a media call with questions?

Want More Information?

Many researchers have written on the uses of quality measurement in child health programs:

Ferris TG, Dougherty D, Blumenthal D, et al. . Pediatrics 2001 Jan;107(1):143-55.

Harris-Kojetin LD, McCormack LA, Jael EF, et al. . Health Serv Res 2001 Jul;36(3):447-76.

Homer CJ, Kleinman LC, Goldmann DA. . Health Serv Res 1998 Oct;33(34):1092-109.

McManus MA, Graham RR, Fox HB, et al. Arch Pediatr Adolesc Med 2000 July;154:665-71.

National Committee for Quality Assurance. Ten steps to a successful report card project: producing comparative health plan reports for consumers. Washington (DC); 1998 Oct.

Simpson L. . Pediatrics 2001 Jan;107(1):171.