NQMC - Criteria for Inclusion of a Quality Measure

Inclusion Criteria

The inclusion criteria of the National Quality Measures Clearinghouse™ (NQMC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, relies on the following definitions:

A patient is a person receiving care or treatment for their health. In NQMC, the phrase "user of care" is synonymous with the word patient. Some measures in NQMC relate to a population or group of persons including users and nonusers of care.
Clinical is an adjective indicating of or for the treatment of patients.
Quality of care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.¹
A measure is a mechanism to assign a quantity to an attribute by comparison to a criterion.
A quality measure is a mechanism to assign a quantity to quality of care by comparison to a criterion.
Clinical performance is the degree of accomplishment of desired health objectives by a clinician or health care organization.
A clinical performance measure is a subtype of measure that is a mechanism for assessing the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in the optimal time period.

Clinical performance measures can be classified into the following five domains:

A process of care is a health care service provided to, on behalf of, or by a patient appropriately based on scientific evidence of efficacy or effectiveness.
An outcome of care is a health state of a patient resulting from health care.
Access to care is a patient's or enrollee's attainment of timely and appropriate health care.
Experience of care is a patient's or enrollee's report concerning observations of and participation in health care.
Structure of care is a feature of a healthcare organization or clinician relevant to its capacity to provide health care.

Two additional domains are available to classify other types of measures if those measures are used in conjunction with clinical performance measures as part of a measure set:

A use of service is the provision of a service to, on behalf of, or by a group of persons defined by geographic location, organizational or non-clinical characteristics without determination of the appropriateness of the service for the specified individuals. Use of service measures can assess encounters, tests, interventions as well as the efficiency of the delivery of these services.
Population health is the state of health of a group of persons defined by geographic location, organizational affiliation or non-clinical characteristics. (Eligibility for measures of population health is not restricted to recipients of clinical care.)

Criteria for Inclusion of Measures in NQMC

To be included in NQMC, a measure must meet all of the following requirements:

The measure must address some aspect(s) of health care delivered to or indicated for persons that 1) receive care from or could receive care from a defined individual, group of individuals or organization(s), or 2) are defined by geographic location, organizational affiliation, or other non-clinical characteristics.
The measure must be in current use or currently in pilot testing and must be the most recent version if the measure has been revised. A measure is in current use if at least one health care organization has used the measure to evaluate or report on quality of care within the previous three years.
The submitter must provide English-language documentation that includes at least each of the three following items:
- The rationale for the measure
  
  The rationale is a brief statement describing the specific aspect of health care and the recipients to which the measure applies. The rationale may also include the evidence basis for the measure, and an explanation of how to interpret results, if that information is provided.
- A description of the denominator and numerator of the measure (including specific variables for inclusion or exclusion of cases from either the denominator or numerator).
- The data source(s) for the measure
  
  Note -- a continuous variable statement (e.g., "time to thrombolysis") may be an acceptable alternative and measures whose metric is other than a rate or percentage will be considered on an individual basis. Structure measures, which lack a numerator and denominator, must meet criterion # 7 concerning supporting evidence for structure measures.
The measure must relate to at least one of the following domains (The submitter should indicate the one domain that fits the best.):
- Process of care
- Outcome of care
- Access to care
- Experience of care
- Structure of care
- Use of Services
- Population Health
At least one of the following criteria must be satisfied with specific information attached in each case:
- The measure has been cited in one or more reports in a National Library of Medicine (NLM) indexed, peer-reviewed journal, applying or evaluating the measure's properties.
- The submitter provides documented peer-reviewed evidence evaluating the reliability and validity of the measure.
  
  Reliability is the degree to which the measure is free from random error.
  
  Validity is the degree to which the measure is associated with what it purports to measure.
- The measure has been developed, adopted, adapted, or endorsed by an organization that promotes rigorous development and use of clinical performance measures. Such an organization may be at the international, national, regional, state or local levels (e.g., a multi-state consortium, a state Medicaid agency, or a health organization or delivery system).
  
  Note -- Adapted measures are those measures developed by one organization, and then subsequently adopted and modified in some way by another organization.
For clinical performance measures (domains of process, outcome, access, patient experience, and structure), the measure must incorporate a clear criterion of quality (i.e., if two results derived using the same measure differ, then the measure supporting documentation must define whether the higher of the two results represents better or worse quality than the lower result). Measures that do not meet this criterion will be included only if they are part of a measure set or collection that includes measures incorporating a clear criterion of quality.
For clinical performance measures (domains of process, outcome, access, patient experience, and structure), the submitter should provide documentation that the most current review of the evidence appropriate for the measure domain, on balance, supports the quality criterion.
For process measures, evidence that the measured clinical process has led to improved health outcomes.

For outcome measures, evidence that the outcome measure has been used to detect the impact of one or more clinical interventions.

For access measures, evidence that an association exists between the access measure and the outcomes of or satisfaction with care.

For patient experience measures, evidence that an association exists between the measure of patient experience of health care and the values and preferences of patients/consumers.

For structure measures, evidence that an association exists between the structure measure and one of the other four domains of quality listed above (e.g., process, outcome, access, and patient experience).

The documentation must consist of at least one of the following types of evidence:
- One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
- A systematic review of the clinical literature
- A clinical practice guideline or other peer-reviewed synthesis of the clinical evidence
- A formal consensus procedure involving experts in relevant clinical, methodological, and organizational sciences.
- Focus groups
Additionally, for patient experience measures, evidence should include focus groups involving patients and/or cognitive testing of the measures by patients. For access and structure measures, the consensus panel should also include other relevant stakeholders.

For use of services measures and population health measures, submission of evidence supporting the need for monitoring is encouraged.
For clinical performance measures, the designated process, outcome, access, experience, or structure must be somewhat or substantially under the control of the health care professionals, organizations² and/or policymakers to whom the measure applies.

For measures of process, outcome, access, and experience, the denominator must be restricted to a population eligible for the designated access, experience, process or outcome.

Note: If the measures do not meet one or more of these inclusion criteria, the submission forms will be returned to the submitter with a request for further documentation or development in the identified area. The submitter may revise and resubmit measures.

Send questions regarding the NQMC Inclusion Criteria to info@qualitymeasures.ahrq.gov.

¹Institute of Medicine. Lohr KN, editor(s). Medicare: a strategy for quality assurance. Vol. 1. Washington, DC: National Academy Press; 1990. p. 21.
²Institute of Medicine, Committee on the National Quality Report on Health Care Delivery. Hurtado MP, Swift EK, Corrigan JM, editor(s). Envisioning the national health care quality report. Washington (DC): National Academy Press; 2001. Chapter 3, Selecting measures. Box 3.1 Desirable characteristics of measures. p. 83.

Inclusion Criteria

Criteria for Inclusion of Measures in NQMC

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