Internal Quality Measures: The Missing Link to High Performance

Internal Quality Measures: The Missing Link to High Performance

internal quality measures

After working with hundreds of health care organizations over the last few years, I’ve found that almost all the organizations I’ve worked with have a difficult time integrating quality measures beyond what is required as part of their financial contracts.

For example…

  • One primary care clinic thought they were doing well with monitoring depression because they were recognized for top performance by one of their payers. Unfortunately, they realized that the measure was only calculated for their patients that were enrolled with that health plan, and when they re-ran the measure on their entire patient population, they discovered a different situation.
  • One hospital thought their patient satisfaction was decreasing because their percentile rank was down but when they calculated their percent positive rate, they realized they had been improving but just not at the rate of their peers.
  • One Accountable Care Organization realized that despite having quality measures for all their providers and clinics, they did not have the aggregate, ACO-level metrics they needed to initiate conversations around direct-to-employer contracts.

What I’m noticing is that the highest performing teams are better because of their orientation to performance measurement. Rather than just using the quality metrics that are put on them by payers as part of their value-contracts, high performers use their own quality metrics to monitor and improve performance.

Quasi-Quality Measurement

Health care providers are busy, value-based care programs are on the rise and the capabilities of EHRs to pull quality data for reporting is limited. In short, the time that is required to measure the quality of services has exceeded what is available. The impact of this situation is that providers and teams spend more time working on collecting data for reporting and less on creating internal measurement systems that would help improve processes.

So, if we want to improve health care quality, how can we offload the burden of quality measurement? The good news is that we’ve already seen positive strides from some leading organizations like CMS, NCQA, and NQF to harmonize their measure specifications, as well as seeing better measure alignment across payers. But this still doesn’t address the data obstacles that are associated with calculating quality measures. Until there is a more effective way to measure quality, there will always be this unbalanced situation where a tremendous amount time is spent on quality but not on quality improvement. So, the question becomes, how can we tackle the data obstacles related to measurement? This is where technology comes in.

Decrease Manual Labor to Boost Performance

Not surprising, in an industry troubled with convoluted processes yet held to standards, more organizations are turning to technology to take their performance to the next level. Understanding that “Quality is everyone’s responsibility”, we here at KPI Ninja feel it is our responsibility to help you tackle these data roadblocks.

Internal Quality Measures


“Quality is everyone’s responsibility”

– Dr. W. Edwards Deming

Traditional approaches to quality improvement through reporting are fundamentally flawed. Evaluating health care services based on administrative billing codes doesn’t measure the true quality of services. Neither does pulling certain codes of an EHR system. The problem is compounded when measure specifications vary program to program. We here at KPI take a different approach to supporting our clients’ reporting and operational needs.

Our process is to start by understanding your goals and looking at the ways in which we can use technology to reduce inefficiencies. For example, if an organization is trying to improve performance but only a few executives are looking at measure rates a few times a year, we ask “How do the clinicians know how they are performing?” As a result of not knowing the impact of their work, teams can end up devaluing the metrics because they do not connect them with their daily work. So, we seek to understand everything we can about the data obstacles, all while considering how we can provide solutions to help the team perform their best. We not only build quality measures to program specifications, but we also build measures that are aligned to your priorities to help you monitor and improve your processes. Internal measures can vary widely but taking the examples from above, here are a few of the ways we’ve supported clients with quality measures that support their internal improvement goals:

  • One primary care clinic knew of the importance of preventative care so to improve health screenings, like depression, the team created a screening metric to use in their daily huddle to clearly identify how many care gaps existed within that day’s patient list and then reflect on how successful they were in closing those gaps that day.
  • Wanting patients to have a positive experience during their stay, one hospital created an internal satisfaction metric that combined data from patient satisfaction surveys, charge nursing rounding results and patient grievance reports to give them a more rounded perspective of how patients were experiencing their care.
  • An Accountable Care Organization that witnessed better improved health outcomes from an innovative care model created an executive scorecard that displayed the organization’s trended performance across all categories of performance (financial, quality, experience, timeliness, etc.).

While quality must be reported externally, true quality is created internally. Our quality services offer the full spectrum of measurement, not just certified measures, to help you see quality measurement as an operational asset to change people’s lives, rather than an administrative burden.


Renee Towne

About the Author
Renee Towne
Director of Quality Programs at KPI Ninja, Inc.
Renee provides operational leadership of quality initiatives at KPI Ninja. Towne has a background in occupational therapy, education and experience in operational excellence across a variety of healthcare domains. Based on prior experience as a clinician that drove outcomes patient by patient, she is leaving a larger footprint by improving health care more comprehensively, population by population.


About KPI Ninja
KPI Ninja is a data analytics company that helps healthcare organizations accelerate their quality, safety, and financial goals with a unique combination of software and service. We are differentiated by our signature mix of technology, performance management consulting and healthcare expertise. We don’t merely offer software solutions but work shoulder to shoulder with clients to help them draw on the power of analytics and continuous improvement methodologies to become more efficient. In harmony with our data-centered ethos, we truly believe that our success is strongly co-related with yours.

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