Determining Which Performance Measures Are Needed
Sites that offer SRH services should select, measure, and assess at least one intermediate or outcome-based performance measure on an ongoing basis.
Structure and process-based performance measures can also be used to better determine how to improve quality. For core components of SRH care for which there are no validated performance measures, teams may use quality measures (for example, unvalidated indicators) to support local QI activities, but not public reporting. When evaluating the need, quality, acceptability, and priority of a specific performance measure, clinical service sites can consider three key factors:216
- Importance. Is the focus of the measure supported by evidence that it is an important component of quality? Is the topic important to measure and report—for example, does it address a priority aspect of health care? Is there an opportunity for improvement?
- Scientific Acceptability. What is the level of evidence for the measure (for example, that a change in the measure is likely to represent a true change in health outcomes)? Does the measure produce consistent (reliable) and credible (valid) results about the quality of care?
- Feasibility. Are the results meaningful, understandable, and useful information for QI? Can the measure be implemented without undue burden (for example, captured with electronic data or electronic health records)?
Using the list in Exhibit 17, service delivery sites can select at least one intermediate or outcome-based performance measure. This non-exhaustive list of measures aligns with the QFP recommendations, the Centers for Medicare and Medicaid Services (CMS) core set of Adult and Child Health Care Quality Measures,* and the approved and HRSA-supported WPSI recommendations.+
The measures on the list have been developed by a variety of entities such as the National Committee for Quality Assurance (NCQA), Partnership for Quality Measurement (PQM), Quality Payment Program, and HRSA’s National Performance Measures. These measures are used to assess quality in many federal and nonfederal programs. The exhibit highlights measures that are ready to implement and actionable, such as the Person-Centered Contraceptive Counseling (PCCC) measure, and other valid and reliable measures, such as those for STI screening rates and access to appointments. It also includes a range of structure-, process-, and outcome-based measures.
Additional resources for selecting and understanding the best ways to use reporting measures include the following:
- Medicaid Adult Core Set Reporting Resources
- Medicaid Child Core Set Reporting Resources
- PQM Submission Tool and Repository Measure Database
- WPSI aligned performance measures
Exhibit 17. Examples of Performance Measures for SRH and Related Services
- Access measures not specific to SRH care
Sample Measures Type of Measure Steward and/or Endorsing Entity Getting timely appointments, care, and information PRO-PM Consumer Assessment of Healthcare Providers and Systems (CAHPS); PQM 0005 How well providers communicate with patients PRO-PM CAHPS; PQM 0005 Helpful, courteous, and respectful office staff PRO-PM CAHPS; PQM 0005 - Contraception
Sample Measures Type of Measure Steward and/or Endorsing Entity Contraceptive Care – Most & Moderately Effective Methods*+ Intermediate Outcome OPA MME; PQM 2903 Contraceptive Care – Access to LARC*+ Structure OPA LARC; PQM 2904 Contraceptive Care – Postpartum Access to LARC*+ Structure OPA Postpartum LARC; PQM 2902 SINC-Based Contraceptive Care – Non-Postpartum Intermediate Outcome University of California – San Francisco (UCSF) eCQM; PQM 3699e SINC-Based Contraceptive Care – Postpartum Intermediate Outcome UCSF eCQM; PQM 3699e Person-Centered Contraceptive Counseling (PCCC) Measure PRO-PM UCSF PCCC; PQM 3543 * Denotes inclusion in CMS Adult and Child Health Care Quality Measures.
+ Denotes measure is in the approved and HRSA-supported WPSI recommendations.
LARC = long-acting reversible contraceptive.- Sexually Transmitted Infections and HIV
Sample Measures Type of Measure Steward and/or Endorsing Entity Chlamydia screening and follow up* Process NCQA Chlamydia screening in women*+ Process NCQA; PCQM 0033 Human Papillomavirus Vaccine for Female Adolescents (HPV) Process NCQA HIV/AIDS: Sexually Transmitted Diseases-Screening for Chlamydia, Gonorrhea, and Syphilis* Process HRSA HIV linkage to care Process HRSA * Denotes inclusion in CMS Adult and Child Health Care Quality Measures.
+ Denotes measure is in the approved and HRSA-supported WPSI recommendations.- Language
Sample Measures Type of Measure Steward and/or Endorsing Entity L1A: Screening for preferred spoken language for health care Process George Washington University L2: Patients receiving language services supported by qualified language services providers Process George Washington University - Other Preventive Health Services
Sample Measures Type of Measure Steward and/or Endorsing Entity Breast Cancer Screening for average risk women*+ Process NCQA; PQM 2372 Cervical Cancer Screening* Process NCQA; PCQM 0032 Screening for Depression and Follow-Up Plan+ Process CMS * Denotes inclusion in CMS Adult and Child Health Care Quality Measures.
+ Denotes measure is in the approved and HRSA-supported WPSI recommendations.- Wellness Preventive Visit
Sample Measures Type of Measure Steward and/or Endorsing Entity Well-Woman Visit*+ Process HRSA Adolescent Well-Visit*+ Process HRSA * Denotes inclusion in CMS Adult and Child Health Care Quality Measures.
+ Denotes measure is in the approved and HRSA-supported WPSI recommendations.