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Perfomance Measures

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Performance measurement is the process of using a tool based on research (a "performance measure") to evaluate a managed organization, plan or program. A responsible, providing entity can be identified, is held accountable for its observed behavior, and has a reasonable degree of control over the aspect of care being evaluated in what the term "performance" implies.

The term "measurement" implies that the approach being used is rigorous and systematic. It also has to be quantifiable.

In many industries performance measurement is a type of evaluation that is used. For example, a common way of evaluating car performance is to calculate miles per gallon, a performance measure. This is a simple ratio of the number of miles driven divided by the number of gallons of gas consumed. Performance measurement is now increasingly common in health care as well.

Some examples of application of performance measurement are the percentage of children age 2 who receive the appropriate immunizations. This, too, is a simple ratio of the percentage of children age 2 with the appropriate immunizations divided by the total number of children age 2 in the applicable population (health program, MCO, State, etc.).

Another example is the percentage of parents reporting "not a problem" in obtaining a specialist referral for their child. Again, this is a simple ratio of the percentage of parents reporting "not a problem" divided by the total number of parents in the applicable population who have requested a specialist referral for their child.

Another characteristic is that a performance measurement tool must be objective, be based on scientific evidence, and not affect or distort results. Expert consensus is often used to reach agreement on precise definitions and measurement specifications in health care performance measurement today. It must be tested to ensure that it is reliable. Use of the tool results in the same reading regardless of who does the measuring or when and where the measurement is taken.

Another important aspect of a performance measurement tool is validity. The tool measures what is intended. It has to be standardized. Definitions of data elements, data collection, and data analyses are sufficiently precise and comprehensible that they can be understood and applied in the same way regardless of who refers to or applies them. These aspects are important in developing a performance measurement tool. The greater the difficulty will be in using the measurement information to compare health plan or program performance results or in answering specific questions about health care being provided the further a measure is from these ideal technical conditions.

Not why the performance is as it is, but performance measurement results describe an observed level of performance (immunization rate, rate of parental satisfaction with referrals). Results cannot reveal which factors account for differences in measured levels of performance.

Here is an example. Factors affecting immunization rates may include provider payment systems, parental or provider education, cultural differences, or underlying economic issues. Answers to such questions require additional investigation and may serve as the starting point for quality improvement efforts or program management initiatives.

A relatively young and evolving field is the use of performance measurement in health care. It is important to bear in mind concerns about problems with data availability, accuracy, and completeness, differences in definitions of basic terms, and failure to meet standards of reliability, validity, and standardization. This is important when assessing potential performance measures.

No standardized set of categories has yet emerged. However, performance measures can apply to various aspects of health care.

Some older methods are still widely used today. Avedis Donabedian, M.D., a pioneer in the science of measuring health care quality, established a set of quality categories involving structure, process, and outcomes.

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