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Measuring quality in hospitals in the United States

Mark W Friedberg, MD, MPP
Bruce Landon, MD, MBA, MSc
Section Editors
Andrew D Auerbach, MD, MPH
Hilary Sanfey, MD
Deputy Editor
Judith A Melin, MA, MD, FACP


Since the early 1990s, health plans in the United States have been measuring and publicly reporting their performance on measures of quality of care. In part, this was a response to health care purchasers who sought better information about the quality of care they were purchasing. Performance measurement and reporting has now become commonplace in most health care settings.

Predated by regional efforts [1], national efforts to measure and report hospital performance on quality measures began with a pilot program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, subsequently renamed "The Joint Commission") [2]. Beginning in 2001, the Joint Commission, the Centers for Medicare and Medicaid Services (CMS), the American Hospital Association, and other organizations formed the Hospital Quality Alliance (HQA) as a mechanism through which hospitals could submit performance data to CMS [3,4]. Hospital participation in the HQA has been voluntary. However, the Medicare Modernization Act of 2003 made receipt of a hospital's full Medicare payment updates contingent upon reporting the initial 10-measure "starter set" to CMS. Consequently, the vast majority of acute care hospitals in the United States participate in this reporting.

Hospital-level performance data, which can be searched by geographic location, category of health condition (eg, general, medical, surgical), and quality measure are available to the public at the Hospital Compare website. The original "starter set" reported in 2004 reflected processes of care for only three health conditions (acute myocardial infarction, heart failure, and pneumonia), which are among the most common and clinically important reasons for hospitalization among Medicare beneficiaries [3,4]. The range of measures reported on Hospital Compare has been expanding and now includes measures of process quality for additional conditions, risk-adjusted mortality, patient experience, and utilization of health care, including utilization of imaging services and readmissions, and structural measures such as participation in a cardiac surgery registry and use of safe surgery checklists. While all of these measure types are important, this review focuses on process measures of hospital performance, as defined below.


Despite having higher health care spending per capita than the health care systems of other industrialized countries, compelling evidence accumulated over the last two decades suggests that the quality of care delivered by the United States health care system is suboptimal [5]. A core principle of quality improvement is that what is not measured cannot be improved. Consequently, performance measurement and reporting has become ingrained in our health care system.

The ultimate goal of quality measurement and reporting systems is to improve care and outcomes. Efforts to improve documentation without changing the content of clinical care are unlikely to achieve this goal. For quality measurement and reporting efforts to be successful, hospitals and clinicians must engage in efforts to understand the root causes of poor performance and develop fundamentally better systems of patient care that will lead to improved performance across a broad range of potential measures.

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Literature review current through: Nov 2017. | This topic last updated: Aug 17, 2016.
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