Founder of ACLP’s Quality & Safety SIG, David Kroll, MD, director of quality and safety for the Psychiatry Department at Brigham and Women’s Hospital, leads new thinking on business issues in occasional articles for ACLP News

Where Do Quality Measures Come From?

And how we could develop our own quality measure

I don’t want to sound like a broken record, but measuring quality in C-L psychiatry is hard. On the one hand, there’s no consensus among C-L psychiatrists on what we should measure amongst ourselves; and on the other, we haven’t yet established a consistent way for C-L psychiatry services to demonstrate their value publicly. Where do we even start?

Remember that, in health care, a true quality measure is a tool that is used by Centers for Medicare & Medicaid Services (CMS) to measure performance in quality initiatives such as MIPS (Merit-based Incentive Payment System). This means that money is at stake—at least for someone—and when money is at stake, hospital systems pay attention.

A quality measure’s development often starts and ends with CMS, but that isn’t absolutely necessary as long as it goes through CMS. In other words, CMS develops many of its own measures, but other groups can also do so and, after sufficient testing, submit their measures to CMS for approval.

Typically, the groups that develop measures are large organizations that already have a major stake in health care quality, like the National Committee for Quality Assurance, but medical societies (for example, the American Psychiatric Association—or even the ACLP) can do so as well. It is a cumbersome process that takes years (and a lot of money), but CMS provides a fairly straightforward template for it. It’s called the “Blueprint,” and it can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html if you’d like to read it. It’s only 394 pages.

What the Blueprint describes is a systematic method for developing quality measures that matter to patients in areas that are considered to be high-impact for CMS. There are five key stages in the process, and after each stage, measure developers must seek approval from CMS to advance to the next. Virtually all of the stages also require convening a technical expert panel (TEP) and posting its work for public review, which adds to the time and expense of the project, but also ensures its transparency.

Measure Conceptualization entails identifying areas where quality improvement would have a meaningful impact on patient outcomes. Ideally, this aligns with CMS’s pre-defined quality strategy and its Annual Call for Measures, which is published online.

Next, Measure Specification describes the process of developing and defining the measure. Measures need a numerator and a denominator, a list of inclusion/exclusion criteria, and an evidence-based rationale for its use. Measure Testing refers to the investigation of whether the measure can be reported consistently and whether it effectively supports CMS’s quality programs.

During Measure Implementation, the developers submit the measure for recommendation by the National Quality Forum and plan for its rollout.

And finally, the Measure Use, Continuing Evaluation and Maintenance phase is the actual rollout of the measure. Once a measure has reached this stage, it requires a Measure Steward (often the developer, but not always) to continually assess its usefulness and update it as needed until it is ready for retirement. Measures are ready for retirement when they demonstrate failure to support the quality program; become redundant after the introduction of a newer, better measure; or prove so successful that they are no longer needed.

Trying to develop a quality measure applicable to C-L psychiatry services would be a big commitment for the ACLP to undertake on its own. But if that’s our goal, we wouldn’t need to do it on our own.

Most organizations hire help for this, and although that would require money there are grants available for this purpose. And we’re allowed to collaborate. For example, the APA collaborated with the American Medical Association and the Physician Consortium for Performance Improvement on the development of Quality ID #325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions, and the APA now stewards that measure.

We could similarly partner with other organizations that have different resources and perhaps more experience in this area—if we wanted to, and if only we can make a compelling case to them for why it’s important.

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