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Quality Measures: How to Improve Quality Scores in Your Practice

Across the U.S., healthcare professionals strive to deliver high-quality care to the patients who pass through the doors of their practices. However, the American healthcare system faces many challenges that can make meaningful quality improvement difficult. Many health systems are understaffed, lack adequate funding, and are overburdened with managing their patient populations. Amidst these complicating factors, implementing and measuring the effectiveness of quality improvement efforts can feel overwhelming.

Agencies like the Centers for Medicare and Medicaid (CMS) have introduced quality measurement tools and quality improvement score programs to help healthcare providers identify areas where they may be underperforming and reward them for improving care quality. These programs, like CMS’s Merit Incentive Payment System (MIPS) and the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), are used industry-wide to great success.

In this article, we will explore how the healthcare industry defines different quality measures, provide examples of quality improvement measures, and how to improve quality scores in your practice. We will also examine how some CMS programs, like Chronic Care Management (CCM), can help practices improve quality scores by closing gaps in care.  

What are quality measures in healthcare?

Quality measures help healthcare providers evaluate, compare, and address the quality of care delivered to their patients. These measures examine patient progress and outcomes, patient perceptions and satisfaction, and organizational structures and processes. They also give healthcare providers actionable, quantifiable objectives to elevate their care delivery, and they can aid patients in reaching their care goals. 

Quality measures are guided by the broader, preventative and patient-centered focus of the modern healthcare landscape. Implementation of quality measures can include goals like closing gaps in care for patients, reviewing internal documentation processes, or lowering readmission rates for patients with cardiovascular disease.  

The Institute of Medicine (IOM) outlined six primary healthcare quality domains to guide healthcare providers in the standardization of quality improvement and the overall elevation of healthcare.

These six goals are: 

• Safety
• Effectiveness
• Timeliness
• Efficiency
• Equity
• Patient-Centeredness

Learn more: Quality Improvement: Processes & Best Practices in Healthcare 

What are the types of quality measures in healthcare?

There are three types of commonly used quality measures in healthcare: structural measures, process measures, and outcome measures. Developed by physician and health researcher Avedis Donabedian in 1966, “The Donabedian Model” of healthcare quality evaluation is still the most widely used conceptual metric to contextualize and examine quality measures. This three-tiered model provides an interlinked framework to study the effectiveness of quality measures and highlight opportunities for systemic improvement.  

Structural measures

Structural measures encompass the overall context through which care is delivered to patients. This includes the healthcare system’s physical facility, equipment, technological capabilities, software, providers, nurses, and administrative staff. Structural measures assess the available resources, capacity, and staffing of a healthcare practice. 

Structural measures are among the easiest to review and report and are often directly responsible for diminished quality of care. For example, if a hospital does not have enough nurses to appropriately attend to the admitted patients, these patients will likely experience a drop in care quality. Without proper infrastructural support, a healthcare practice cannot deliver high-quality care. Therefore, structural measures are a crucial first step in analyzing and improving the quality of care within a practice.   

Examples of structural measures: 

• Reviewing the patient-to-provider ratio of a healthcare system
• Assessing the number of board-certified physicians on staff
• Inspecting the age and reliability of a practice’s medical equipment  
• Examining whether a practice uses paper-charting or an Electronic Health Record (EHR)

Process measures

Process measures encompass the actions a healthcare provider takes to maintain or improve the health of their patients. Process measures include treatment, diagnosis, surgical procedures, medication prescription, patient education, care coordination, and preventative care. Process measures also cover the interpersonal aspects of care delivery and care management as well as internal and technical processes used by healthcare providers and staff. 

The majority of quality measures in healthcare are process measures. 

Examples of process measures

• The percentage of at-risk patients who received preventative cancer screenings, like mammograms and colonoscopies
• The percentage of patients who received vaccinations and immunizations
• The percentage of diabetic patients who received A1C tests and controlled their blood sugar levels
• The percentage of patients who received thrombolytic therapy within 90 minutes of qualifying symptom onset
• The percentage of patients with cardiovascular disease who received a fall risk assessment during a hospital admission
• The comprehensive review of whether a hospital completed inventory checks 

Outcome measures 

Outcome measures examine the impact the healthcare system has on patients’ clinical outcomes, quality of life, and overall satisfaction. This includes changes to a patient’s health status, resource utilization, complications from clinical interventions, mortality rates, hospital readmissions, improved health literacy and self-management, and changes in lifestyle and behavior. 

Understandably, outcome measures are often heralded as the gold standard of quality measures, since the primary goal of healthcare is to improve the health of the patient. However, outcome measures rarely exist in isolation. They are inextricably linked to the structural and process measures within a given practice. They are further influenced by the Social Determinants of Health (SDOHs) and the broader context of a patient’s life.

Outcome measures often defy clean attribution because of these factors. For example, a patient who adjusts their diet and lifestyle to control their hypertension may have done so because of the care and education they received from their physician. However, their spouse and children’s concerns may have also influenced them to alter their behaviors. Or, a patient may discontinue medications or routine appointments due to an inability to afford care. If this patient dies of their illness, this regrettable outcome cannot be exclusively attributed to the practice.

Outcome measures are still often the most pertinent metrics, as they directly reflect both the adverse and desirable effects of healthcare on a patient’s life. However, outcome measures usually require risk adjustment to account for elements outside of the healthcare system’s control. 

Examples of outcome measures

• The percentage of patients who died after a specific surgical intervention
• The rate of surgical complications developing after a particular procedure
• The percentage of patients who develop an infection or hospital-acquired infection (HAI) after receiving care at a healthcare facility
• The percentage of heart failure patients who were readmitted to the hospital within 30 days of discharge
• The percentage of patients who indicated they were satisfied with their care delivery on a satisfaction survey  

How to measure quality in healthcare

One of the most effective ways to measure quality in healthcare is through quality score initiatives. Quality scores track numerous and diverse quality measures, like readmission rates, patient experience, the rate of preventative care administration, healthcare costs, and interoperability. These programs collate the data they collect and provide healthcare practices and hospitals with scores based on the quality of care provided. 

Some quality measures, like the Overall Hospital Star Rating (Overall Star Rating), provide patients with information to compare local and national hospitals when evaluating treatment options. Others, like MIPS and MIPS Value Pathways (MVPs), offer federal reimbursement for physicians who deliver high-quality, high-value care to their patients. MIPS and its associated programs are part of the Quality Payment Program (QPP), an initiative launched by CMS in 2017. QPP was designed to elevate the quality of care provided to Medicare beneficiaries, lower healthcare costs across the nation, and reward practices for implementing quality measures.   

Traditional MIPS and MVPs

The Merit-based Incentive Payment System (MIPS) is the original quality score program launched by the QPP. MIPS was designed to inspire cost-efficient and high-quality care, drive organizational improvements, reduce expenses, and facilitate better clinical outcomes for Medicare patients. Physicians can choose to participate as individuals or aggregate their scores and participate as a group. MIPS uses four performance categories to assign practices a quality score between 0-100. 

The four performance categories to evaluate scores are:

• Quality: This category evaluates the processes and outcomes of quality measures. This accounts for 30% of the total score.  
• Promoting Interoperability: This category promotes the use of electronic health records (EHRs) to improve patient access to information and care coordination. This accounts for 25% of the total score.
• Improvement Activities: This category measures how physicians improve the delivery of preventative services, accessibility of care, and the engagement of their patients. This accounts for 15% of the total score.  
• Cost: This category assesses the cost of care provided by a physician. This accounts for 30% of the final score.  

Since the introduction of MIPS, CMS has introduced other programs to help practices take advantage of the quality improvement program. MVPs, the newest offering, allow physicians to report on a subset of quality measures focused on a specialty practice or specific medical conditions. This requires a reduced number of quality measures and improvement activities that are more limited in scope than traditional MIPS reporting.

A few examples of MVPs include Advancing Cancer Care, Advancing Care for Heart Disease, Focusing on Women’s Health, and Value in Primary Care, though MVPs can change from year to year. Traditional MIPS will be phased out in 2028, so CMS encourages providers to join MVPs before then. 

Overall Hospital Quality Star Rating (Overall Star Rating)

The Overall Star Rating is a Medicare initiative that provides hospitals with quality scores based on 46 hospital quality measures publicly reported by CMS. These 46 quality measures are broken down into five essential categories:

• Mortality
• Safety of care
• Readmission
• Patient experience
• Timeliness and effectiveness of care

Participating hospitals are assigned a star rating between 1 and 5, based on their performance on the quality measures. These measures include data like the death rate for stroke patients, central line-associated bloodstream infections, the rate of readmission after hip/knee surgery, and the number of patients who reported that their nurses communicated well.

Healthcare Effectiveness Data and Information Set (HEDIS) 

Like Medicare’s Star Rating system, the NQCA’s HEDIS quality improvement program analyzes 96 quality measures across six care domains. The HEDIS domains of care are:

• Effectiveness of care
• Access/availability of care
• Experience of care
• Utilization
• Health plan descriptive information
• Measures reported using electronic clinical data systems

HEDIS is predominantly used to assign quality scores to healthcare plans. As the healthcare landscape increasingly emphasizes value-based care, continuous improvement, and proactive healthcare engagement, health plans must evolve to offer these services to their enrolled patients, all while keeping costs to a minimum. HEDIS helps businesses and consumers compare healthcare plans.

However, since 2008, HEDIS has also been available for use by medical providers and practices. HEDIS therefore empowers individual practices to take proactive steps to improve their quality scores.

How to improve quality scores 

The most potent way to improve quality scores is through implementing preventative care services. Preventative care has a sweeping positive effect across the healthcare industry. It encourages better clinical outcomes, reduced healthcare expenditures and patient costs, lower readmission rates, and improved quality of life for patients. 

Patients who engage proactively with their healthcare journey are likelier to identify chronic diseases in their developmental stages. When chronic diseases are identified early on, they are usually easier to manage and require less expensive and invasive treatment plans. These patients are less likely to become high utilizers of healthcare services or face frequent hospital admissions. 

Engaging, educating, and activating patients in their preventative care journey further encourages adherence to healthy lifestyle behaviors, medications, and wellness plans. Patients who feel confident in their ability to self-manage their illnesses will likely be more satisfied with the care they receive. 

Though healthcare quality scores measure a broad range of factors when calculating their ratings, a deliberate emphasis on preventative services and closing gaps in care will radiate across your healthcare practice and be reflected in your quality scoring.

Examples of preventative services that can improve quality scores:

There are many preventative care services your practice can provide to elevate your quality of care and, consequentially, improve your quality scores. These services include:

• Type 2 diabetes screenings for obese and otherwise at-risk patients
• Fall prevention screenings for patients over the age of 65 or with mobility issues that place them at risk
• Mammograms
• Colorectal cancer screenings
• Lung cancer screenings for those with a history of tobacco use
• Immunizations and vaccinations, including herpes zoster, tetanus/dipitheria, pneumoccal pneumonia, and influenza
• Blood pressure screenings
• Cholesterol screenings 
• Nutritional counseling for obese patients and patients with chronic diseases exacerbated by poor diet
• Alcohol misuse screenings and counseling services
• Depression screenings and other behavioral and mental health services  

Learn more: The Challenges of Delivering High-Quality Care to Patients with Chronic Conditions

Partner with ChartSpan to improve patient outcomes and quality performance 

Many practices face significant challenges when implementing quality measures and seeking to improve their quality scores. Healthcare organizations often lack the necessary bandwidth to dedicate to patient outreach and engagement. 

Fully-managed Chronic Care Management (CCM) programs, like ChartSpan, can help healthcare practices elevate their quality scores by reducing this workload. Medicare beneficiaries enrolled in CCM receive a dedicated monthly call from a care manager, who can assist them in engaging with preventative services and closing gaps in care.

Care managers can also help address socioeconomic factors that may prevent patients from accessing high-quality care, like transportation arrangements or connecting patients to food banks. This directly correlates to score improvement and facilitates improved clinical outcomes for patients. 

ChartSpan also has a wealth of experience navigating and improving MIPS scores for primary care offices, rural clinics, specialty practices, and various other healthcare organizations.  ChartSpan has on-hand quality score specialists who will assist your practice in maximizing MIPS scores. This quality score improvement feature is included at no additional charge with our fully managed CCM program. 

Contact us to explore how ChartSpan’s turnkey CCM program can help your practice improve quality scores.

You may also like: 

• The Ultimate Provider’s Guide to CCM
• 11 Features of the Best Chronic Care Management Companies
• 9 Ways to Increase Patient Retention with Chronic Care Management