Quality Measures - Quality Organizations

With the shift from the fee-for-service model to the pay-for-performance model, there has been an abundance of quality organizations coming to the forefront of healthcare. The following organizations develop evidence-based measures for use by healthcare stakeholders. The majority of them evaluate the performance of healthcare professionals across the continuum, but only one specifically focuses on measures specific to medications and pharmacists’ services.

National Quality Forum

The National Quality Forum (NQF) is a nonprofit organization established in 1999 by a coalition of public- and private-sector leaders after the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. NQF is recognized as a voluntary consensus-standards setting organization – as defined by the National Technology Transfer and Advancement Act of 1995 and the Office of Management and Budget (OMB) Circular A-119 – and adheres to the OMB definition of consensus. NQF aims to improve US healthcare by defining the national goals and priorities for healthcare quality improvement, and to build national consensus around these goals and to endorse standardized performance metrics for quantifying and reporting on national healthcare quality efforts. Quality measure engineers have deemed NQF endorsements the “gold standard” for healthcare performance measures. The credibility of the endorsement comes from the rigorous criteria and versatility of the panelists involved in the approval process. At NQF consensus across the healthcare community drives every aspect of their work.

Learn more about NQF.

National Committee for Quality Assurance 

The National Committee for Quality Assurance (NCQA) seal of approval is an indicator of exceptional management, high-quality care and service for health plans. In order to receive this seal, health plans must meet more 60 standards and report their performance in over 40 areas.  NCQA also audits health plan data by certified auditors to ensure validity.

NCQA’s Health Effectiveness Data Information Set (HEDIS) is a tool utilized by more than 90% of US health plans. It is comprised of 81 measures across 5 domains of care. HEDIS is unique because it allows consumers and purchasers to compare and contrast the performance of health plans using the same set of measures.

HEDIS measures address the following:          

  • Asthma Medication Use
  • Persistence of Beta-Blocker Treatment after a Heart Attack
  • Controlling High Blood Pressure
  • Comprehensive Diabetes Care
  • Breast Cancer Screening
  • Antidepressant Medication Management
  • Childhood and Adolescent Immunization Status
  • Childhood and Adult Weight/BMI Assessment

Learn more about HEDIS measures.

Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) was established to produce evidence to make health care safer, high quality, more accessible, equitable, and affordable. AHRQ works with the U.S. Department of Health and Human Services and other partners to guarantee that collected evidence is efficiently used and thoroughly comprehended by viewers.

To further improve patient care, created the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program to support and promote the assessment of consumers’ experience with health care. The major goals of the program are to:

  • Develop standardized patient questionnaires that can be used to compare results across sponsors and over time.
  • Generate tools and resources that sponsors can use to produce understandable and usable comparative information for both consumers and health care providers.

To achieve these goals, CAHPS provides the following quality measures to payers and others.

Learn more about CAHPS measures.

Centers for Medicare and Medicaid Services

Medicare uses a Star Rating System to measure how well Medicare Advantage and prescription drug (Part D) plans perform. Medicare scores how well plans did in several categories, including quality of care and customer service. Ratings range from 1 to 5 stars, with five being the highest and one being the lowest score. Medicare assigns plans one overall star rating to summarize the plan’s performance as a whole. Plans also get separate star ratings in each individual category reviewed. The overall star rating score provides a way to compare performance among several plans. To learn more about differences among plans, look at plans’ ratings in each category.

Medicare health plans are rated on how well they perform in five different categories:

  1. Staying healthy: screenings, tests, and vaccines
  2. Managing chronic (long-term) conditions
  3. Plan responsiveness and care
  4. Member complaints, problems getting services, and choosing to leave the plan
  5. Health plan customer service

Medicare drug plans are rated on how well they perform in four different categories:

  1. Drug plan customer service
  2. Member complaints, problems getting services, and choosing to leave the plan
  3. Member experience with drug plan
  4. Drug pricing and patient safety

Learn more about CMS Star Ratings.

Pharmacy Quality Alliance

The Pharmacy Quality Alliance (PQA) develops medication-use measures. The measures focus on medication safety, medication adherence and appropriateness. PQA aligns its activities with the National Quality Strategy and uses the National Priorities Partnership as a point of reference for the development of measures. PQA focuses on the priorities identified through the National Priorities Partnership and aligns its activities with the National Quality Strategy. 

Out of the fifteen quality measures in the 2017 Part D ratings, five of them addressing medication safety and adherence are PQA-supported.

  1. High Risk Medication
  2. Medication Adherence for Diabetes
  3. Medication Adherence for Hypertension (RAS antagonists)
  4. Medication Adherence for Cholesterol (Statins)
  5. MTM Program Completion Rate for CMR 

Learn more about PQA Measures.

PQA is a multi-stakeholder member-based non-profit organization with transparent and consensus based measurement development process. Their membership consists of professional associations, patient advocacy groups, government agencies, trade associations, academic institutions, health plans, pharmacy benefit managers, life sciences companies, pharmaceutical companies, and technology vendors. PQA measures are being used in a variety of settings including health plans, pharmacies, accreditation programs, pay-for-performance networks, physician offices, and Medicare Part D Plan ratings.

PQA determines which measures to develop by looking at the needs of the health care system, including gaps in care and in measurement, and aligns their efforts to best fill those gaps. Continuously, PQA conducts an environmental scan of healthcare trends to prioritize the development of measures. PQA measures undergo a rigorous process that takes an average of 12 to 18 months.  PQA uses groups of experts to ensure the value and relevance of their measures. A new measure goes through five major steps: measure concept idea, measure concept development, draft measure testing, measure endorsement, and measure update. As the measure proceeds through the process, various advisement groups and panelists contribute feedback to inform the development of reputable PQA measures.

PQA is also involved in quality improvement. They develop quality improvement indicators (QIIs) for organizations to evaluate themselves internally. QIIs are different from performance measures in that there is at least one criteria in the definition that can’t be standardized across the healthcare system. Thus, QIIs are meant to be tailored to each organization that uses them for their own internal quality improvement processes. QIIs are tools that are just as good for measurement as performance measures, it’s just a matter of the end user’s application to their practice environment.

PQA has grown exponentially in the last decade. With contributions in quality measures and technology advancements, PQA showcases the importance of pharmacist involvement in improving patient care.

The Pharmacy Quality Alliance offers a multitude of services to educate pharmacists and student pharmacists. Their 26 hour CE training program, EPIQ provides free in-depth modules to teach participants (e.g. pharmacists, student pharmacists) about quality measurement and its applications. The goal of the program is to increase competency to better serve patients.