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Research Questions

  1. How are performance measures being used in practice?
  2. What factors are influencing measure use?
  3. What types of system changes have occurred as a result of measure use?
  4. What improvements could make it easier to use performance measures?

The National Quality Forum (NQF), a private, nonprofit membership organization committed to improving health care quality performance measurement and reporting, was awarded a contract with the U.S. Department of Health and Human Services (HHS) to establish a portfolio of quality and efficiency measures. The portfolio of measures would allow the federal government to examine how and whether health care spending is achieving the best results for patients and taxpayers. As part of the scope of work under the HHS contract, NQF was required to conduct an independent evaluation of the uses of NQF-endorsed measures for the purposes of accountability (e.g., public reporting, payment, accreditation, certification) and quality improvement. In September 2010, NQF entered into a contract with the RAND Corporation for RAND to serve as the independent evaluator. This report presents the results of the evaluation study. It describes how performance measures are being used by a wide array of organizations and the types of measures being used for different purposes, summarizes key barriers and facilitators to the use of measures, and identifies opportunities for easing the use of performance measures moving forward.

Key Findings

Measures Serve Internal, Public Needs

  • Public reporting (releasing information about quality of care) and quality improvement were the most commonly reported uses of performance measures.
  • Users reported using measures drawn from seven performance domains: structure of care, process of care, outcome, access, safety, costs, and patient experience, with process measures being the most widely used.
  • A combination of factors is driving use of performance measures, including requirements related to payments based on meeting quality standards and public reporting in the Patient Protection and Affordable Care Act, and the need to respond to local health issues.

After Release, Minimal Interest in Measures

  • Few organizations had studied the results from measuring performance, particularly regarding the return on investment.

New Measures Could Improve Measurement of Care

  • Access measures, among others, are lacking - leading to incomplete information about the care provided
  • Several areas for developing new measures were identified, including coordination of care, outcomes, patient safety, cost and resource use, access and affordability, and measures that address specific conditions, settings, and populations.


  • Establish priorities for where end users should focus their attention and resources.
  • Align measures among the various parties that impose reporting requirements.
  • Develop new measures for emerging applications, such as those in the context of episode-based payments, accountable care organizations, and value-based purchasing.
  • Engage in front-end planning to influence the data architecture of EHRs and other health IT to support the construction of measures
  • Conduct a systematic review of the literature to fully catalog measure use and formally assess the system-change results from the use of measures.

This work was sponsored by the National Quality Forum under U.S. Department of Health and Human Services. The research was conducted in RAND Health, a unit of the RAND Corporation.

This report is part of the RAND technical report series. RAND technical reports may include research findings on a specific topic that is limited in scope or intended for a narrow audience; present discussions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research professionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for research quality and objectivity.

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