Quality Measurement

2016 HIMSS Letter of Recommendations to CMS on Electronic Clinical Quality Measure Development, Implementation, and Reporting Policy for MIPS and other CMS Quality Programs

For the nation’s healthcare providers to have full faith and confidence in the value proposition of eReporting quality measures, HIMSS recommends that any eCQM (retooled or de-novo measure) should be tested and validated to meet the following criteria before being included in the eCQM set for any CMS quality reporting and/or value based purchasing program, including the Merit-Based Incentive Payment System (MIPS):

  • Required data elements for selected eCQMs must be able to be efficiently and accurately gathered in the healthcare provider workflow, and using data elements already collected as part of the care process and stored in the electronic health record (EHR) or other interoperable clinical and financial health information technology. The eCQMs should be easily extractable for reporting purposes.
  • Public reporting of quality data based on eCQMs must accurately reflect the care given by the applicable healthcare provider(s).
  • Any eCQM must be tested, feasibility tested, field tested, and endorsed by the National Quality Forum (NQF) to ensure that the measures produce comparable and consistent results.
  • Selected CQMs should present a clear pathway to value and fit into an analytics capability for use by health care professionals and hospitals as a meaningful scorecard on performance.

2015 Meaningful Use Program Quality Measure Reporting Requirements Fact Sheet

In 2015, eligible professionals and eligible hospitals will be required to attest for a full year's worth of clinical quality measure data in order to receiver EHR Incentive Program (Meaningful Use) incentives from CMS. Learn more about reporting requirements and reporting options for 2015.

EHR-Enabled Quality Measurement and Public Policy in 2014: Alignment and Challenges

Learn how the 2014 Physician Fee Schedule Final will allow providers will be able to establish one workflow to capture and report the same clinical quality measures for both the CMS EHR Incentive Program (Meaningful Use) and the Physician Quality Reporting System (PQRS.) The regulation also approved the creation of CMS approved organizations called clinical data registries which can use certified EHR technology to calculate and electronically reporting the clinical quality measures for Meaningful Use Stage 2 and PQRS on behalf of providers.

Quality Measurement Development and Endorsement

This series of presentations from HIMSS14 Quality Symposium illustrates the ecosystem of quality measurement through the eyes of its players, and provides the understanding and need to keep all components healthy and functional in cooperative symbiosis. 

Measure Application Partnership (MAP) Background
The Affordable Care Act (ACA) assigns new duties to NQF as the consensus-based entity, including convening multi-stakeholder groups to provide input to the Department of Health and Human Services on the selection of performance measures for public reporting and performance-based payment programs. To fulfill this role, NQF has established the Measure Applications Partnership (MAP).

The Measure Applications Partnership (MAP) will operate through a two©\tiered structure (Figure). An overarching, standing, multi-stakeholder Coordinating Committee will set the strategy for the Partnership and provide direction to, and ensure synchronization among, the advisory workgroups. The workgroups will advise the Coordinating Committee on measures needed for specific uses. The Coordinating Committee will provide input to HHS on measures for use in public reporting, performance-based payment, and other programs.

Leadership Colloquia – Sept. 15, 2011 in Washington, DC
As part of its ongoing commitment to the advancement of healthcare quality, NQF convenes healthcare executives annually for an invitational Leadership Colloquium. Each year, the Colloquium focuses on an issue in quality improvement that has a direct impact upon the work and vision of healthcare leaders, executives, and members of the government. The 2011 Leadership Colloquium will be held on September 15, 2011 in Washington, DC.

HIMSS Activities and Announcements

The Patient Safety Webinar Series Continues
More than 5000 people have participated in the Partnership for Patients/National Priorities Partnership (NPP) patient safety webinar series so far. NQF would like to thank our members who have joined the interactive sessions for their participation. Last week's webinar, Decreasing Surgical Site Infections, was the fifth of an eight-part series. If you missed it, you can access the recording.

The next webinar, Minimizing Pressure Ulcers and Falls in Healthcare Settings, will take place September 9 at 1:00 pm ET. Featured speakers Mary Tinetti, MD, director of program on aging at Yale University School of Falls, and Dan Berlowitz, MD, MPH, director of the Center for Health Quality Outcomes and Economic Research at the Veterans Administration, will provide ideas and insights for reducing falls while maintaining patient mobility and reducing preventable pressure ulcers in acute care settings.

Learn more about the Partnership for Patients/National Priorities Partnership webinar series, register for upcoming ones, and access recordings of the webinars that have passed.

NQF Guide for Reading EP and Hospital Measures
This document provides guidance for understanding and using the electronically specified measures identified as 'retooled' that were published as Eligible Provider (EP) and Hospital Measures in .xml and .html format.

RAND Report
A first-of-its-kind RAND report commissioned by the National Quality Forum (NQF) provides important direction for achieving payment reforms to improve healthcare quality. Based on a review of 90 different payment models across the nation, the Payment Reform: Analysis of Models and Performance Measurement Implications report identifies available performance measures for 11 payment reform models and five key areas where new measures are needed to support reforms.

According to the report, the following measure types will be the key to reforms aimed at improving healthcare and achieving better health for all:

  • outcome measures focusing on patient results, from avoidable harms to improved health;
  • care coordination measures capturing appropriate patient follow-up care keeping patients on track to improved health;
  • patient engagement measures assessing whether care empowers patients and caregivers to improve health;
  • organizational capability measures assessing whether new systems are sufficient to deliver high-quality care;
  • composite measures combining results of individual measures into an overall indicator of quality;
  • efficiency measures combining quality and resource use measures; and disparity measures ensuring that cost-cutting efforts don't lead to favoring specific patient types.

Read more about the report >>

Public Reporting of Patient Safety Events Report Now Available
The primary aim of public reporting is to promote learning among providers and consumers regarding the nature and prevalence of safety risks. The National Voluntary Consensus Standards for Public Reporting of Patient Safety Event Information report provides guidance to those who sponsor and produce healthcare quality and safety data reports. It draws on earlier NQF work related to consumer-focused public reporting while focusing on the unique characteristics of patient safety event reporting.

Congratulations to Maggie Lohnes, RN, FHIMSS HIMSS Patient Safety & Quality Outcomes Committee Member: Selected to serve on the National Priorities Partnership (NPP) Evaluation Advisory Panel formed to provide feedback and insight on the evaluation's theoretical framework and overarching research questions. The panel also will provide periodic comment on other elements of the evaluation.

Framework for Public Reporting of Patient Safety Events
NQF has endorsed a framework for the public reporting of patient safety events. The framework provides seven guidelines that address issues to consider in patient safety event reporting, such as how to convey low-frequency events, ways to protect patient confidentiality when reporting errors, and guidance on using data from trusted sources. It also works in concert with NQF's ongoing work to improve safety in healthcare, which includes maintaining Safe Practices, Serious Reportable Events, and work to endorse additional patient safety measures. Read the press release for more details.

Current Participation
- Participating in bi-monthly HIT Work User Group, first meeting held on Tues, September 28. It's purpose is to bring stakeholders (EHR users, vendors, quality measurement community) together to create a constructive virtual forum for shared learning around eMeasure implementation and other components of the quality infrastructure. User group members will share their experiences and lessons learned including successes, barriers and greatest challenges (e.g., human, technology, interface, vendor product) and collectively learn from each other. Over time, we anticipate highlighting best practices, formal Q&As, and other implementation resources and tools. - David Collins, MHA, CPHQ, CPHIMS, FHIMSS - HIMSS Director Healthcare Information Systems

  • Participating in one of NQF's eight Member Councils is one of the chief ways that members can help advance a meaningful agenda to improve healthcare quality through measurement and public reporting.
    • HIMSS is assigned to the Quality Measurement, Research and Improvement (QMRI) Council
  • Members of the Quality Measurement, Research and Improvement Council are organizations that conduct research, education, or initiatives to improve healthcare quality, measurement, and reporting. The Council also includes accrediting bodies, policy and quality centers, and information and data services providers. Members of this Council are entrenched in the everyday measurement, evaluation and research of quality in healthcare. Their expertise in healthcare quality is essential to NQF members as they consider new measures, practices and guidelines for endorsement.

The eight Member Councils convene regularly by conference call and meet in-person twice a year at NQF's Spring and Fall Conferences to discuss matters of interest to NQF and the organizations they represent. These interactions offer NQF members additional opportunities to build important relationships with their peers in the healthcare industry. In addition, cross-council discussion is encouraged through meetings and conference calls that address ongoing and emerging issues, such as safe practices and health information technology. - Louis H. Diamond, M.B.Ch.B., F.A.C.P., F.C.P. (S.A.), FHIMSS is Chair of QMRI

Past Participation

  • Call for Comments: CDS Expert Panel
    HIMSS Response: HIMSS applaunds NQF efforts. In conjunction with other recent national efforts, the work is likely to advance progress toward widespread availability of highly interoperable, usable and effective CDS that promotes improved patient safety and quality of care.
  • Participated in National Priorities Partnership - In-Person Meeting, September 21, 2010 - 8:30AM - 2:00PM in Washington, DC, to discuss NPP's input to the Secretary of the Department of Health & Human Services (HHS) on priorities for the Secretary's national strategy for health care quality improvement. More information is available on the NQF Events page. - Louis H. Diamond, M.B.Ch.B., F.A.C.P., F.C.P. (S.A.), FHIMSS - Chair, HIMSS Patient Safety & Quality Outcomes Committee, and David Collins, MHA, CPHQ, CPHIMS, FHIMSS - HIMSS Director Healthcare Information Systems
  • -Participated in the National Priorities Partnership Care Coordination Convening Workshop, September 1-2, 2010, Washington. D.C. James Holly, MD, HIMSS Patient Safety & Quality Outcomes Committee Member

NQF Resources

NQF Guide for Reading EP and Hospital Measures
This document provides guidance for understanding and using the electronically specified measures identified as 'retooled' that were published as Eligible Provider (EP) and Hospital Measures in .xml and .html format.

NPP's Recommendations to HHS: Eight National Priorities and Goals (11/16/2010)
The National Priorities Partnership (NPP) recently delivered its recommendations to U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius for a set of eight national priorities and goals. HHS contracted with NQF to ask NPP to provide input on a proposed framework for the National Quality Strategy and offer recommendations for a set of national priorities and goals. Learn more

NQF Releases Reports to Promote Clinical Decision Support and Appropriate Health IT Use (1/6/2011)
Washington, DC (January 6, 2011) The National Quality Forum (NQF) released two new reports¡ªDriving Quality: A Model to Measure Electronic Health IT Use and Driving Quality and Performance Measurement: A Foundation for Clinical Decision Support. In direct support of the Health Information Technology for Economic and Clinical Health Act (HITECH) in the American Recovery and Reinvestment Act (ARRA), NQF's work will promote effective use of health IT tools, ensure a stronger health IT infrastructure, and help improve America's healthcare system. Read more

CDS Driving Quality & Performance Measure: A Foundation for CDS Report
Health IT Utilization: Driving Quality - A Health IT Assessment Framework for Measurement Report

NQF Webinar: Improvements to the Consensus Development Process
The 1/19/2011 webinar provided an overview of NQF's response and proposed actions to a recent external evaluation of the CDP by Mathematica. NQF's Consensus Development Process (CDP).

Care Coordination Report and Quality Connections Issue Now Available
As the number of healthcare professionals, care settings, and treatments involved in a patient's care has increased, coordinating care has become both more difficult and more vital. Poorly coordinated care often results in wasted healthcare dollars and poor care for patients. Recognizing the need for care coordination, NQF has released two publications on the topic: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination consensus report and Quality Connections: Care Coordination. The report and resource paper provide valuable information on the care coordination process and the next steps in improving care coordination throughout the healthcare system.

NQF Health Information Technology projects at a glance:
Webinar: The Journey to Excellence
Webinar: The Role of HIT in Quality Improvement


NQF All member call (6/13/11)
The topic for the June 13th NQF all member call was the Measure Application Partnership.

Measures Application Partnership Presenters:
• Beth McGlynn, PhD, Director, Kaiser Permanente Center for Effectiveness and Safety Research & Co-Chair Measures Application Partnership Coordinating Committee
• Tom Valuck, MD, JD, NQF Senior Vice President, Strategic Partnerships
• Nalini Pande, JD, Senior Director, Strategic Partnerships


HIMSS has released its "Call for Action" for 2011/2012, summarizing the Society's top policy priorities for the 112th Congress and the Obama Administration. (3/16/2011)