Quality Measures - Background & History

The Pharmacy Quality Alliance defines quality as the degree to which services or products are evaluated or to which services or products meet the expectations of the consumer.

The movement toward quality-driven healthcare has been gaining traction since the Affordable Care Act was passed in 2010. However, quality measurement and improvement has been an important part of healthcare since the 1850s. Florence Nightingale advocated for an increase in sanitation and hygiene standards to increase the morale of soldiers during the Crimean War. Since then, organizations have been established to address and improve the quality of healthcare.

Great strides to drive the healthcare system towards high quality care delivery took place during the conception of government insurance. The 1965 establishment of the Medicare and the Medicaid programs as Title XVIII and Title XIX of the Social Security Act catalyzed the quality movement. It introduced a review process and brought attention to the identification of ways to continuously improve care. However, the legislation stopped short of requiring formal evaluations for providers or adjustment to provider payments based on the quality of care.

In a 1972 effort to assess the quality and appropriateness of care, Congress established projects through physician sponsored Experimental Medical Care Review Organizations. The results from these pilot projects fueled the quick establishment of Medicare’s Professional Standards Review Organizations (PSROs). PSROs were developed with the intention of affirming Medicare’s expectations of physicians providing high quality services. However, PSROs were rendered unsuccessful in both improving quality and containing costs, and were quickly replaced by the utilization and quality control Peer Review Organizations (PROs).  PROs met the expectations that existed for the PSROs; as a result, they are still used under the Centers for Medicare and Medicaid Services (CMS) label of Quality Improvement Organizations (QIOs).

The academic health quality movement has also played a pivotal role in bringing evidence to the attention of healthcare stakeholders. The National Academies of Science established the Institute of Medicine (IOM) in 1970, which has since contributed to the enhancement of quality of healthcare services. In the late 1980s, The Joint Commission on Accreditation of Healthcare Organizations (now The Joint Commission), which evaluates healthcare organizations and provides guidance to optimize quality and value, introduced accreditation standards based on a 1966 article entitled “Evaluating the Quality of Medical Care.” The article by Avedis Donabedian, presented the structure-process-outcome paradigm, which is still used as the framework for quality measures.

As more research became available to healthcare agents, more organizations were created to further address quality. In 1989, the Agency for Healthcare Research and Quality (AHRQ) was created to replace the National Center for Health Services Research. AHRQ was created by Congress in response to newly reported data that revealed a variety of practice models across the nation and inappropriate procedural treatments. Then in 1990, the National Committee for Quality Assurance (NCQA) was established to improve health care quality by managing accreditation programs for individual physicians, health plans, and medical groups.

Later in 1998, the Quality of Health Care project was launched by the Institute of Medicine (IOM) to reach a threshold improvement in health care quality over a 10-year period. The results of the study were released as “To Err is Human: Building a Safer Health System.” The report exposed the numerous safety gaps in the system and highlighted the astronomical number of deaths associated with medical errors. Later, IOM released “Crossing the Quality Chasm: A New Health System for the 21st Century” which added to the evidence of a failed health care system with claims of the US health systems lacking accessibility to consistent, high-quality care. These two reports played a pivotal role in increasing the nation’s commitment to improving the quality of the U.S. health care and to assisting providers with the implementation of quality measures in their practices.

Since then, quality metrics have evolved and have been adopted by several professions including pharmacy. In 2006, CMS spearheaded the formation of the Pharmacy Quality Alliance (PQA) with the argument that if the government was going to spend billions on prescription drug benefit (Part D), then there needed to be mechanisms to measure the quality of the benefit. APhA was an initial organization at the table. PQA was established as a multi-stakeholder, consensus-based membership organization that collaboratively promotes appropriate medication use and develops strategies for measuring and reporting performance information related to medications.

As the nation continues to make great strides towards enhancing the patient experience and outcomes, pharmacists must also continue to be involved in the quality measurement process to ensure they are included in the team-based approach to quality.