The annual National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report shows a largely positive picture of the healthcare industry and its uptake of quality measures. It’s not surprising: Every report that has come out has shown good, sometimes great results for various metrics. Some have more direct impact on patients than others.

Among the findings:

  • 95% of the of 119 publicly reported measures in seven programs showed improvement in rates between 2006 and 2012, with process measures most likely to be the highest performers. The report noted that the rates were so high on about a third of these measures that the return on continued investment in these measures may be “marginal” in terms of patient outcomes.
  • Because of this, process measures may have a limited lifetime, and one suggested action is to work with the National Quality Forum on ways to retire measures that have done their job and leave little to improve.
  • Few measures have a clear relationship between them and positive patient outcomes, although some related to cardiac and surgical care did have an impact. The report says more outcomes-based measures are needed.
  • Disparities in care are improving but still exist, and the healthcare industry as a whole needs to work on how to best measure outcomes for various groups and then improve those outcomes.

“It’s always gratifying to see we are getting results and measurable improvement and going in a positive direction,” says Paul L. Green, MS, RN, CPHQ, principal for quality and safety advisory services at Premier Performance Partners, a healthcare consultancy in Charlotte, NC. “But we are seeing a clear move away from process metrics. We have seen improvement over 20 years, but not in terms of outcomes related to those process measures.”

Maybe there is some improvement in mortality or injury, but not as much as the improvement that you see in the rates of the process itself, Green says. That means either process measures aren’t a good way to measure outcomes, or the ones we have chosen as a stand-in aren’t good enough. So look for CMS and other regulators to put a lot more emphasis on outcomes, including patient-reported outcomes, Green says.

“This will be resource-intensive for quality departments,” Green says. “In the late 1990s, we tried to look at some of these in Minnesota, and it was so hard to gather data in a meaningful way that we stopped. Things have moved on since then in terms of technology, but they have also moved on in other ways. We have to figure out what happens not just within the hospital, but elsewhere on the continuum and collect data from there.”

The Physician Quality Reporting System, which may be unknown to many hospitals that don’t have their own physician practices, is something that all hospitals need to get to know, says Green. “You need to understand the data that physicians collect in their offices, too. You will have to be more educated in outpatient and community-based healthcare. Until now, the linkages from skilled nursing facilities, rehab, home care, and physicians have often been missing. That can’t continue.”

There remain some legal issues about sharing data, as well as the continuing issue of interoperability for organizations that want to share data but don’t have technology that can talk to each other, says Green.

One metric he says will likely be very important in the future is the first efficiency measure for CMS, Medicare spending per beneficiary, which goes from three days before to 30 days after a hospitalization. “But most hospitals don’t have the capability to get that information, and just gathering that data will require cooperation.”

The biggest driver of your success in the future, Green says, will be your ability to coordinate along the continuum of care and act as a referee among all the various pieces. Staying at the center of this new wheel “will help you be more aware of what the issues are, so you can create, measure, and improve coordination efforts.”

Even though the report is making these recommendations for the future, he says it’s important to start now to build the relationships with the others in your community with whom you may not have a close working relationship. “The emphasis on processes will drop and outcomes will increase, and outcomes will involve everyone on the continuum.”

Everyone includes the patient, which is another ingredient to the recipe that a lot of hospitals have put off adding. “The level of improvement we have seen in process measures hasn’t been replicated in patient satisfaction, and that is concerning. You have to step that up,” he says.

Pay attention to patient engagement and communication, and to building partnerships with your patients. Get them involved in your quality programs — deeply involved. “Studies show that even with bad outcomes, if you are transparent and open and put the patient at the center, they are less likely to sue,” he says.

The report lays out the future clearly, Green says: Focus on collaboration with every cog in the wheel, focus on outcomes, and focus on efficiency. “The places where we have spent our work lives are going away. It’s a new world for everyone, and your job is to understand all the parts.”

The entire report can be found at

For more information on this topic, contact Paul L. Green, MS, RN, CPHQ, Principal, Quality and Safety Advisory Services, Premier Performance Partners, Charlotte, NC. Email: