The ACS and the ABCs of how quality measures are established and implemented

Common acronyms associated with quality measures

Multi-stakeholder, consensus-based quality measurement is central to the delivery of safe, accessible, patient-centered, and affordable care. The Institute of Medicine’s report To Err Is Human, published in 1999, has been credited as the impetus for shifting the U.S. health care system toward an emphasis on improved quality of care achievable through new initiatives, such as public reporting and pay for performance.1 This changing environment led to the creation of multi-stakeholder organizations charged with improving quality and reducing cost.

Through effective partnerships, the American College of Surgeons (ACS) has served as a motivating force in the drive to improve the quality of surgical care. The ACS has played a leadership role, and is recognized as a key contributor to the development, validation, and implementation of national quality measures.

The College has contributed its insights and services to a number of national organizations, agencies, and programs that are involved in creating a road map for improved quality of care and developing strategies aimed at creating change in health care delivery. This article outlines the roles of these various entities and details the College’s contributions to their endeavors.

Creating a road map

With the passage of the Patient Protection and Affordable Care Act (ACA), the federal government has demonstrated a commitment to ensuring the delivery of safer and more transparent, efficient, and patient-centered care. This commitment is articulated through the identification of national priorities and financial incentives designed to drive the types of changes in practice that are believed to lead to less waste and higher quality care. Also crucial to this commitment are mandates requiring the public reporting of information on physicians, including the upcoming mandatory reporting of quality measures on Medicare’s Physician Compare website.2

Figure 1. National Quality Strategy4

The National Quality Strategy (NQS) is the framework outlined in the ACA and subsequently interpreted and developed by the Secretary of the U.S. Department of Health and Human Services (HHS) with multi-stakeholder input. The NQS is designed to guide the development and prioritization of quality measurement. The NQS also forms the backdrop for the national quality initiatives with the aim of developing a “transparent collaborative process that shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health,” as mandated in the ACA.3

As a result of this mandate, the NQS provides a context for quality measurement, measure development, and measure alignment across federal reporting initiatives, as well as analysis of where stakeholder resources can be used to increase efficiency and accountability in health care. The NQS pursues three aims: better care, healthy people/healthy communities, and more affordable care. To accomplish these aims, NQS focuses on the following priorities: health and well-being, prevention and treatment of leading causes of mortality, person and family-centered care, patient safety, effective communication and care coordination, and affordable care (see Figure 1).4

NQF’s priority setting efforts

National Priorities Partnership (NPP). What sets NQF apart among quality care organizations is that it was selected by HHS to fulfill a provision in the ACA which requires a consensus-based entity to convene multi-stakeholder groups to provide input to HHS on the development of the NQS.5 As mentioned previously, the foundation of the NQS is to build a national consensus on how to measure quality and facilitate stakeholders to align their interests. In response to this mandate, the NQF convened the NPP to identify goals and measures of the NQS priorities, to provide annual input to HHS on progress toward the goals, and to offer guidance on strategic opportunities for improvement.5 The NPP is represented by 51 national organizations inclusive of public and private stakeholder groups.

Figure 2. Measure Application Process National Quality Forum. Measure Application Partnership: Identifying the “Right” Measures for Public Reporting and Performance‐Based Payment. Distributed at the NQF 2012 annual meeting on April 4, 2012.

Measure Applications Partnership (MAP). For the first time in national quality measure development, the ACA made way for significant enhancements to the traditional federal rulemaking process by providing a forum for public and private partnership to provide feedback prior to rulemaking. HHS selected the NQF to provide this pre-rulemaking input. To fulfill this expectation, the NQF convened the MAP, which is charged with identifying core measures and prioritization of measure gaps in federal quality programs and measure alignment across programs, settings, levels of analysis, populations, and between public and private sector programs (see Figure 2).6 The MAP consists of four main workgroups: clinician, hospital, post‐acute care/long‐term care, and dual eligible beneficiaries—all of which are overseen by the Coordinating Committee. This committee includes members representing consumers, businesses, and purchasers, labor, health plans, clinicians and providers, communities and states, and suppliers.6 As noted in Table 1, the ACS is actively involved in MAP and the development of its recommendations through member appointments and by providing comments on various measures that the Centers for Medicare & Medicaid Services (CMS) has chosen for inclusion in federal quality incentive programs.

Leaders in developing quality measures

AMA Physician Consortium for Performance Improvement (PCPI). One of the leading measure developers in physician QI is the PCPI, convened by the American Medical Association. The PCPI is a nationally recognized organization that has set the standard for the development of physician-level quality measures among a broad range of clinical topics encompassing structure, process, and outcome measures.7 PCPI focuses on clinically meaningful, evidence-based performance measures, which are reviewed by PCPI member-appointed work groups, which may include members with expertise in performance measurement methodology and clinical content.8 Members may include purchaser, employer, health plan, and consumer and patient representatives.8 Measures are also vetted through public comment and PCPI member voting. This broad-based approach to measure development works to minimize bias and to measure what is important and actionable for physicians.

Table 1: ACS representation within national quality organizations

PCPI tests measures for feasibility, reliability, validity, and unintended consequences through their testing protocol that further establishes the evidence base for each PCPI measure. These measures are continuously subject to an ongoing process of testing and maintenance that prepares measures for measure endorsement and implementation.

As a result of PCPI’s evidence-based, cross-specialty, multidisciplinary process, this group has been the leading steward in measure development for national accountability and quality improvement physician programs, such as the Medicare Physician Quality Reporting System (PQRS) and the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Stage 1 (EHR Meaningful Use Program). The PCPI has developed more than 280 measures, and more than 57 percent of measures in PQRS in 2011 and 45 percent of measures in the Stage 1 EHR Meaningful Use Program have been developed by the PCPI.9 PCPI has also taken the lead in enabling use of measures in EHRs. As part of this initiative, PCPI created the National Quality Registry Network (NQRN), which facilitates the standardization and interoperability of quality data across patient registries.10

The ACS—in collaboration with the Surgical Quality Alliance (SQA)—has partnered with PCPI on the development, maintenance, and endorsement of the PCPI Perioperative Care Measure Set. The ACS and SQA have provided evidence-based data to support and refine the measures aimed at improving the use of appropriate antibiotic and venous thromboembolism prophylaxis. As part of this partnership, which resulted in well-validated measures, PCPI perioperative care measures have been selected to be included in federal quality improvement programs, enabling the surgical community to more easily participate in the PQRS. The College also contributes to PCPI’s efforts through representation on the PCPI executive committee, Fellow appointments to various work groups, and through public comment to ensure that measures developed by PCPI account for the unique nature of surgery.

Other Measure Developers. CMS and the Agency for Healthcare Research and Quality (AHRQ) are the leading federal agencies in quality measure development. Several independent not-for-profit organizations also have focused their efforts on consensus-based measure development, including The Joint Commission and the National Commission for Quality Assurance (NCQA). Lastly, in addition to the PCPI and the ACS, several professional medical societies have focused on quality measures development, including The Society for Thoracic Surgery, The American College of Cardiology, the Society for Vascular Surgery, and the American Academy of Ophthalmology.

Validating quality measures

National Quality Forum (NQF). The NQF is an independent not-for-profit organization that has set the standard for the science of quality measurement validation in the national quality landscape. NQF provides quality measures with “NQF endorsement” based on a rigorous multi-stakeholder consensus-based measure review. NQF endorsement represents the gold standard in measure development. To receive endorsement, measures must meet the following criteria:

  • Importance to measure and report to keep focus on priority areas to maximize positive effects on health care quality
  • Scientifically acceptable, so that the measure, when implemented, will produce reliable and valid results about the quality of care
  • Useable and relevant to ensure that intended users (consumers, purchasers, providers, and policymakers) can understand the results of the measure and find them useful for quality improvement and decision making
  • Feasible to collect with data that can be readily available for measurement
  • Assess related and competing measures11

NQF’s consensus development process (CDP) is based on transparency and multi-stakeholder consensus to determine whether each measure meets the endorsement criteria. Each workgroup that reviews a measure for possible endorsement has representation from the following NQF Councils: Consumer Council; Health Plan Council, Health Professionals Council, Provider Organizations Council, Public-Community Health Agency Council; Purchaser Council; Quality Measurement, Research and Improvement Council; and Supplier and Industry Council. The Consensus Standards Approval Committee (CSAC), which includes a diverse set of health care stakeholders, determines if consensus was met among all NQF councils and whether the measure met NQF criteria. The CSAC then recommends endorsement to the NQF Board of Directors. Measures are endorsed for three years, entered into maintenance, and then are re-evaluated based on NQF endorsement criteria.

The ACS is a member of the Health Professionals Council and represents the surgical perspective in several relevant NQF workgroups, including on the CSAC. The ACS monitors and analyzes measure development and NQF policies while also voting regularly and providing comments to proposals and frameworks. The measure endorsement stage is a crucial time for the College to provide input because the measures endorsed by NQF are most likely to be the measures that CMS selects for inclusion in federal incentive programs, which determine physician bonus payments and the metrics used for public reporting.

Implementing quality measures

AQA. The AQA—once known as the Ambulatory Quality Alliance—is a multi-stakeholder quality organization that focuses on facilitating measure implementation by addressing the gap between quality measurement and improvement. The AQA represents more than 100 organizations including clinicians, consumers, purchasers, and health plans. The mission of the AQA is to improve patient safety, health care quality, and value in all settings where members develop consensus and promote strategies for quality measure implementation, collect and aggregate relevant data, and report relevant information on this data to inform decision making and with the aim to improve patient outcomes.12

Guided by David B. Hoyt, MD, FACS, ACS Executive Director and chair of the Strategic Planning Committee, the AQA has revised its role in the health care system redesign with the creation of a strategic plan to meet the needs of the quality community. As outlined in the strategic plan, the AQA plans to work with other quality organizations to facilitate alignment across public and private efforts.

The AQA also plans to analyze and promote “best practices” to fill the gap between measurement and improvement. This effort includes identifying measures that had the most success in driving improvement and investigating additional levers of QI such as certification and professionalism. Lastly, the AQA plans to work on providing guidance to HHS on quality initiatives such as the NQS and public reporting programs. The ACS has been consistently represented on AQA workgroups and committees and will continue to work in collaboration with the AQA as the strategic plan is implemented.12

Table 2: Sample quality measure step-by-step (While this is a sample case study, this is not reflective of all processes for measure development.)

The Quality Alliance Steering Committee (QASC). This committee is a collaborative effort of a variety of stakeholders vested in the implementation of quality improvement initiatives that focus on making information on quality improvement and the cost of care consistent, useful, and widely available to consumers, providers, and public and private payors. Through the High Value Health Care Project, the QASC is developing a solution for more efficient data aggregation and integration, measuring cost and efficiency for high-priority clinical conditions, and advancing equity in health care among racial and ethnic groups.13The ACS works in partnership with the QASC through representation on their committees to ensure that initiatives are inclusive of the needs of surgical patients.

Sample step-by-step quality measure case study

Table 2  illustrates the steps involved to increase the likelihood for the inclusion of a quality measure in a federal quality reporting program (or ensuring that a bad measure is not included), and it is a long, multi-layered process. The College has been heavily involved in measure development and endorsement, and monitors and acts at all levels of the measure development enterprise to help ensure that the perspective of the surgical patient is at the center of measure development.

As the national quality landscape evolves, the ACS will continue to strengthen its leadership and guidance as national quality organizations work to implement ACA mandates throughout the health care system redesign. The College aims to deliver evidence-based information from the surgical perspective so that quality measurement, endorsement, and implementation will be accurately and fairly implemented according to surgery’s unique nature. ACS input is more important now than ever as we work with quality organizations to interpret ACA mandates, ensuring that efforts accurately measure and publicly report care delivered to surgical patients.


  1. Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  2. Physician compare. Available at: Accessed July 2, 2012.
  3. Agency for Healthcare Research and Quality. Affordable Care Act. Section 3011. Available at: Accessed July 02, 2012.
  4. National Quality Forum. Input on measures under consideration by Health and Human Services for 2012 rulemaking: Final Report (NQF). Available at: Accessed July 2, 2012.
  5. National Quality Forum. National priorities partnership. Available at: Accessed July 2, 2012.
  6. National Quality Forum. Measure Application Partnership. Available at: Accessed July 2, 2012.
  7. American Medical Association. PCPI and PCPI-approved quality measures. Available at: Accessed July 2, 2012.
  8. American Medical Association. PCPI leadership and government. Available at: Accessed July 2, 2012.
  9. American Medical Association. PCPI orientation presentation. Available at: Accessed July 3, 2012.
  10. American Medical Association. The Physician Consortium for Performance Improvement. National Quality Registry Network Coordinating Task Force. Available at: Accessed July 3, 2012.
  11. National Quality Forum. Measure evaluation criteria and guidance summary tables. Available at: Accessed July 5, 2012.
  12. AQA Alliance. AQA member meeting. Strategic Planning Report. Available at: Accessed July 5, 2012.
  13. Quality Alliance Steering Committee. High-value health care project. Available at: Accessed July 5, 2012.

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