Practice Performance Measurement

Practice performance measurement addresses the organization and promotion of safe and high quality care. The purpose of this section is to provide tools and strategies to help evaluate physician performance and the patient/family perspective regarding the quality of their care. Collecting data on performance, sharing these data with clinicians, staff and families and being transparent with patients and families will help drive medical home improvement. Please note that this page provides additional resources as to what is provided in the Practice Performance Measurement section of the Building Your Medical Home toolkit.

The Institute of Medicine has identified six dimensions of quality which include care that is effective, efficient, equitable, timely, patient-centered, and safe. Quality can be viewed from both a clinical and operational perspective:

• Clinical quality improvement focuses on the scope of improvement of clinical outcomes.
• Operational quality includes the business operational aspects of healthcare delivery in practices.
• Other dimensions such as equitable care, patient access, and patient-centered care further expand the scope of quality.

The Model for Improvement, the Plan Do Study Act [PDSA] model, is extensively utilized by the Institute for Healthcare Improvement [IHI]. The PDSA model has been successfully applied in several inpatient and outpatient healthcare settings to improve clinical quality and patient outcomes. However, in addition to clinical improvement using the PDSA model, there are other business models for quality that can significantly impact operational quality in healthcare. This includes the LEAN methodology which aims at eliminating waste in processes to enhance efficiency. In contrast to methodologies that aim to improve existing healthcare processes, Management Sciences offers a proactive approach of using operations research to improve flow, revenue, and safety in hospital and clinic office settings.

Further, quality improvement results occur as a product of teamwork. Teamwork involves a set of skilled cross-disciplinary interactions that are learned, practiced and refined to provide better care delivery management, promote safety, and enhance outcomes. 

The commitment to quality improvement is implicit in the Academy's mission of promoting the health and well-being of all children. The Academy has enhanced its range of programs, resources, and tools, as well as its relationship with external agencies and organizations to decrease the quality gap and provide optimal health care quality to all children. For more information on quality improvement at the Academy, click here.

Medical Home Interview Videos
Developed by the National Center for Medical Home Implementation

• What is the Role of Quality Improvement in Medical Home?
  W. Carl Cooley, MD, FAAP
• What is the Role of Quality Improvement in Medical Home?
  Chuck Norlin, MD, FAAP
• How Does Quality Improvement Enhance Medical Home?
  Thomas S. Klitzner, MD, PhD, FAAP
• How Can Families Be Involved in the Quality Improvement Process?
  Lee Partridge
• When Does a Practice Become a Medical Home?
  W. Carl Cooley, MD, FAAP
• How Has Data Collection Helped to Enhance Your Medical Home?
  Jennifer Lail, MD, FAAP

Further Reading

• National Strategy for Quality Improvement in Health Care (National Quality Strategy)
  This strategy, issued by the US Department of Health and Human Services (HHS), was called for under the Affordable Care Act and is the first effort to create national aims and priorities to guide local, state, and national efforts to improve the quality of health care in the US. Priority areas include effective care coordination and person-and-family centered care for all children and adults.
• Health Resources and Services Administration (HRSA) Quality Improvement Web Site
  This Web site aggregates QI resources, as well as QI information from HRSA federal and non-federal partners, including patient safety tools, quality indicators, and a health measure inventory.

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Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home
Developed on behalf of the National Center for Medical Home Implementation by Rebecca A. Malouin, PhD, MPH, this monograph presents various tools available and in use to identify, recognize, and evaluate a practice as a pediatric medical home. Because no one tool is recognized as the de facto tool to assess pediatric practices, a review of the relative merits of existing tools will help inform purchasers, payers, providers, and patients in evaluating pediatric practices. The tools reviewed in this monograph include:

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Child Primary Care Questionnaire 2.0 (beta)
• Components of Primary Care Instrument (CPCI)
• Family-Centered Care Self-Assessment Tool
• Medical Home Index (MHI) and Medical Home Family Index (MHFI)
• Medical Home Implementation Quotient (MHIQ)
• Measure of Processes of Care (MPOC)
• Primary Care Assessment Survey (PCAS)
• Primary Care Assessment Tools (PCAT)
• Promoting Healthy Development Survey (PHDS)
• Physicians Practice Connections – Patient-Centered Medical Home (PPC-PCMH)
• Parent’s Perceptions of Primary care (P3C)
• Young Adult Health Care Survey (YAHCS)

American Academy of Pediatrics (AAP) Resources

• Quality Improvement—Quality Measurement
  This page highlights the continued AAP efforts to monitor national efforts on quality measurement and is participating with other organizations to develop, review or endorse pediatric quality measures.
• Education in Quality Improvement for Pediatric Practice (EQIPP)
  EQIPP courses are designed to help pediatricians identify and close the gaps in  practice using practical tools, document  improved quality care on a continuous basis, earn CME credit, and meet MOC Part 4: Performance in Practice requirements all at once. By using EQIPP, a pediatrician can collect data to measure current levels of care at baseline and improve care through Plan, Do, Study, Act (PDSA) cycles.
  • EQIPP: Medical Home for Pediatric Primary Care
    The goal of the EQIPP: Medical Home for Pediatric Primary Care course is to help pediatric health care providers create plans for improvement to address gaps identified in key activities of the medical home. This EQIPP course will focus on the following key activities related to medical home:
    • Developing a highly functioning, multidisciplinary quality improvement team
    • Knowing and manage your patient population
    • Enhancing access to care
    • Providing family-centered care
    • Providing and document planned, proactive, comprehensive care
    • Coordinating care across all settings
• Quality Improvement Innovation Network (QuIIN)
  The mission of the QuIIN, a network of practicing pediatricians and their staff, is to improve care and outcomes for children and families. QuIIN does so by using quality improvement science to test practical tools, measures, and strategies for use in everyday pediatric practice, the child's medical home, as well as by informal assessment that provides practicing pediatrician perspective into evidenced based recommendations and tools for implementation. QuIIN quality improvement projects use QI science, including measurement.

Agency for Healthcare Research and Quality (AHRQ) Resources

• Care Coordination Accountability Measures for Primary Care Practice
  This report presents selected measures from the Care Coordination Measures Atlas divided into two sets: Care Coordination Accountability Measures (from the patient/family perspective) and Companion Measures (from the health care professional and system perspectives; ie, self-assessment). Pediatric measures featured in this report include the following:
  • Care Coordination Accountability Measures
  • Primary Care Assessment Tool—Child Edition (PCAT-CE)
  • Alternative: Family-Centered Care Self-Assessment Tool—Family Version
  • Companion Measures for Health Care Professionals
  • Family-Centered Care Self-Assessment Tool— Provider Version
  • Primary Care Assessment Tool - Provider Version (PCAT-PE)
  • Care Coordination Measurement Tool (CCMT)
  • Companion Measures for System Representatives
  • Medical Home Index (MHI-LV)
  • Primary Care Assessment Tool—Facility Edition (PCAT-FE)
• Child Version of the CAHPS Clinician and Group Visit Survey
  The Visit Survey asks patients to report on their experiences with providers and office staff at their most recent visit to a doctor's office. The CAHPS Clinician and Group Child Visit Survey 2.0 can be used to assess the experiences of children and their parents during the child’s most recent visit with a provider. To learn more, visit Read about the CAHPS Visit Survey.
• Measuring Patients' Experiences with Medical Homes Using the CAHPS PCMH Item Set (Archived Webinar)
  AHRQ hosted a webinar on the development and anticipated uses of the new Patient-Centered Medical Home (PCMH) Item Set.
• Why Improve Patient Experience? How To Justify the Effort
  The CAHPS Improvement Guide highlights the clinical and business benefits associated with improving patients' experiences with ambulatory care. This section of the Guide can help health care organizations make a compelling case for identifying and addressing performance issues revealed by CAHPS survey scores.
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Podcast Series on QI
  This resources is a series of CAHPS podcast on improving patients’ experiences with care is now available. The QI podcast series will feature speakers from a variety of organizations around the country who share both their professional expertise and their experiences using CAHPS surveys to assess and improve the quality of care they deliver.
• Child Health Care Quality Toolbox
  Concepts, tips, and tools for evaluating the quality of health care for children.
• Improving Evaluations of the Medical Home
  This brief offers a concise description for decision makers of why and how to commission effective evaluations of medical home demonstrations. It provides insights into what outcomes to assess, why to include control practices, and why not accounting for clustering can doom an evaluation.
• Building the Evidence Base for the Medical Home: What Sample and Sample Size Do Studies Need?
  This white paper provides information about how to determine the effect sizes a given study can expect to detect, identifies the number of patients and practices required to detect policy-relevant, achievable effects, and demonstrates how evaluators can select the outcomes and types of patients included in analyses to improve a study's ability to detect true effects.
• TalkingQuality Podcasts
  These podcasts discuss a variety of topics such as making practice quality reports user-centered, how social media can draw patients to a quality report, branding your quality report, and more.
• National Quality Measures Clearinghouse (NQMC)
  NQMC is a public resource for evidence-based quality measures and measure sets. Measure summaries are organized by topic, organization, or domain, and can be compared side-by-side. The Tutorial on Quality Measures provides an introduction to the field of quality measurement and how to best use NQMC.
• Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide
  This how-to guide shows ways to support organizations interested in starting a practice facilitation program. Practice facilitation is a strategy to improve primary health care processes and outcomes through the creation of an ongoing, trusting relationship between an external facilitator and a primary care practice.

Child and Adolescent Health Measurement Initiative (CAHMI)

• Measuring Medical Home
  This manual compiled by the CAHMI takes a look at the medical home concept and components. For a copy of the manual with complete appendices, you can click here .

The Commonwealth Fund

• Evaluating Medical Home Adoption in the Safety Net
  The patient-centered medical home (PCMH) model could be particularly valuable in safety-net clinics, which provide primary care for over 18 million medically underserved patients. With Commonwealth Fund support, Jonathan M. Birnberg, MD, of the University of Chicago, and colleagues have developed an evaluation scale customized for safety-net clinics.
• Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality
  This brief describes a recommended core set of standardized measures to evaluate the patient-centered medical home for both adults and children. Core recommended pediatric measures include well-care visits, medication management of asthma, immunizations, and more.

Institute for Healthcare Improvement (IHI)
Some of the offerings on the IHI Web site include:

• Knowledge Center—the content "library" featuring tools, change ideas, measures, improvement stories, and other resources to support improvement efforts
• Explore by Interest—provides a more in-depth look at key topic areas by gathering content from across the site
• IHI Offerings—hosts information on training and skill-building learning opportunities
• User Communities—features such as blogs, wikis, and discussion boards available soon
• Explore by Interest—allows for deeper content searches by topic, care setting, role, etc. For example, see the Improve Primary Care Access page

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Agency for Healthcare Research and Quality (AHRQ)

• AHRQ Health Care Innovations Exchange
  The AHRQ Health Care Innovations Exchange provides a central repository of searchable innovations and QualityTools that enables health care decisionmakers to quickly identify ideas and tools that meet their needs classified by disease or clinical category, patient population, stage of care, setting of care, etc.
  • Frontline Innovators on Changing Care, Improving Health
    This video series features stories about the value of implementing innovations to improve patient-centered care, including a program that reduces school absences and unnecessary emergency department for inner city children using telemedicine. 
  • National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes
• The CAHPS Improvement Guide—Practical Strategies for Improving the Patient Care Experience

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
Institute of Medicine—September 2012
This report explores opportunities to use emerging technology and science to address getting better value from our health care. Applying these strategies can support a continuously learning health system, one that aligns science and informatics, patient-clinician partnerships, incentives, and a culture of continuous improvement to produce the best care at lower cost.

Child and Adolescent Health Measurement Initiative (CAHMI) Data Resource Center (DRC)

• Making National Survey Data Come Alive
• National Profile of Children with Special Health Care Needs and Autism Spectrum Disorders: Key Findings from the 2009/10 NS-CSHCN & 2007 NSCH
• Your State Data… Your Local Story— Local Uses of National and State Data

Case Study—Colorado Children's Healthcare Access Program: Helping Pediatric Practices Become Medical Homes for Low-Income Children
The Commonwealth Fund—June 2010
A recent evaluation that shows children covered by Medicaid and with a medical home in a private pediatric practice supported by CCHAP visit the emergency department less often, have more preventive care visits, and are less expensive for the state Medicaid program than children in non-CCHAP-affiliated practices.

Collaborating With Medicaid to Improve Health Care to Multi-Payer Alliances
Aligning Forces for Quality (AF4Q)
This paper illustrates how and why Medicaid agencies are aligning their quality improvement strategies with other payers, and includes case studies from Oregon and South Central Pennsylvania to illustrate improved care quality and a reduction in disparities.

Medical Homes: The Transformation of Pediatric Primary Care in Connecticut
Child Health and Development Institute of Connecticut, Inc
This issue brief summarizes recent policy changes in Connecticut regarding Person Centered Medical Homes (PCMH) and outlines supports for practices transforming to medical homes. The brief highlights the efforts of the state to advance the medical home concept of care as the optimal health care delivery system for children.

Medical Home Quality and Readmission Risk for Children Hospitalized With Asthma Exacerbations
This article published in Pediatrics discusses how the medical home model of care has the potential to have a positive effect on outpatient outcomes for children with asthma. However, a gap exists in information to assess the impact of medical home quality on health care utilization after hospitalizations. The research discussed in the article highlights the authors’ exploration of the relationship between medical home quality and readmission risks in children hospitalized with asthma exacerbations. The conclusions of the article state that “Among measured aspects of medical home in a cohort of hospitalized children with asthma, having poor access to a medical home was the only measure associated with increased readmission. Improving physician access for children with asthma may lower hospital readmission.”

Powerful Partnerships—A Handbook for Families and Providers Working Together to Improve Care
National Initiative for Children’s Healthcare Quality (NICHQ)
This guidebook provides insight and advice to make the most of the partnerships between family members and health providers on quality improvement teams.

Pennsylvania practice achieves improved care for patients with asthma, along with top certification
Wyckoff AS. AAP News. 2009;30(11):26.

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Access to the Medical Home: New Findings From the 2005-2006 National Survey of Children With Special Health Care Needs
Strickland BB, Singh GK, Kogan MD, Mann MY, Van Dyck PC, Newacheck PW. Pediatrics. 2009;123:6;e996-e1004

Agency for Healthcare Research and Quality (AHRQ)

• Child Health Research—Identifying Quality Problems and Improving Care
• Closing the Quality Gap: Revisiting the State of the Science—The Patient-Centered Medical Home

The Association Between Having a Medical Home and Vaccination Coverage Among Children Eligible for the Vaccines for Children Program
Smith PJ, Santoli JM, Chu SY, Ochoa DQ, Rodewald LE. Pediatrics. 2005;116;130-139

Associations Between Quality of Primary Care and Health Care Use Among Children With Special Health Care Needs
Raphael JL, Mei M, Brousseau DC, Giordano TP. Arch Pediatr Adolesc Med. 2011;165(5):399-404.

Coping Among Parents of Children With Special Health Care Needs With and Without a Health Care Home
Drummond A, Looman W, Phillips A. Journal of Pediatric Health Care. 2011

County Health Rankings & Roadmaps: What Works for Health
This program helps communities create solutions that make it easier for people to be healthy in their own communities, focusing on specific factors that affect health, such as education and income.What Works for Health, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin, provides an online searchable menu of policies and programs focusing on factors that make communities healthier places to live, learn, work and play, including a section on the medical home.

Early Evaluations of the Medical Home: Building on a Promising Start
Mathematica Policy Research and Agency for Healthcare Research and Quality (AHRQ). 2012

Effect of Hospital-Based Comprehensive Care Clinic on Health Costs for Medicaid-Insured Medically Complex Children
Arch Pediatr Adolesc Med. 2011

Evidence for Family-Centered Care for Children With Special Health Care Needs: A Systematic Review
Academic Pediatrics . 2011;11:136-143

Impact of Medical Homes on Quality, Healthcare Utilization, and Costs
The American Journal of Managed Care
This article published in discusses the results of a study conducted by HealthCore of Empire Blue Cross Blue Shield data that demonstrates better health outcomes and lower costs in patient-centered medical home (PCMH) practices. Adults and children treated in a PCMH had 12% and 23% lower odds of hospitalization, and required 11% and 17% fewer emergency department services, respectively, than patients that did not receive care in a PCMH. Risk-adjusted total per member per month costs were 8.6% and 14.5% lower for pediatric and adult patients treated in in a PCMH, respectively.

Implementing Patient-Centered Medical Home Pilot Projects, Lessons from AF4Q Communities 
Robert Wood Johnson Foundation

Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care
Cooley WC, McAllister JW, Sherrieb K, Kuhlthau K. Pediatrics. 2009;124;358-364

Improvement in the Family-Centered Medical Home Enhances Outcomes for Children and Youth with Special Health Care Needs
McAllister JW, Sherrieb K, Cooley WC. J Ambulatory Care Manage. 2009;32(3)188-196

The Medical Home: Growing Evidence to Support a New Approach to Primary Care
Rosenthal TC. The Journal of the American Board of Family Medicine. 2008;21(5):427-440

The Medical Home, Preventive Care Screenings, and Counseling for Children: Evidence from the Medical Expenditure Panel Survey
Romaire MA. Acad Pediatr. 2010;10(5):338-45

The Patient-Centered Medical Home: A Review of Recent Research
Hoff T, Weller W, DePuccio M. Medical Care Research Review. 2012

Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics
Lewis SE, Nocon RS, Tang H; Young Park S, Vable AM, Casalino LP, Huang ES, Quinn MT, Burnet DT, Summerfelt WMT, Birnberg JM, Chin MH. Arch Intern Med. 2012;172(1):23-31.

Patient-Centered Primary Care Collaborative (PCPCC)

• Benefits of Implementing the Primary Care Patient-Centered Medical Home: Cost and Quality Results (2012)
  This report and a corresponding fact sheet that serve to update earlier reviews of cost and quality data for patient-centered medical homes that were published in 2009 and 2010. The report provides a summary of 34 recent peer reviewed and industry reports from patient-centered medical home (PCMH) initiatives from the past two years, highlighting cost and quality outcomes data. The report also defines the features of a PCMH and provides data from 23 case studies to demonstrate how each feature of a PCMH contributes to lower costs, improved care and better health outcomes. 
• Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States (2010)

The Pediatric Alliance for Coordinated Care: Evaluation of a Medical Home Model
Palfrey JS, Sofis LA, Davidson EJ, Liu J, Freeman L, Ganz ML. Pediatrics. 2004;113(5 Suppl):1507-16

Primary Care Attributes and Mortality: A National Person-Level Study
Jerant A, Fenton JJ, Franks P. Ann Fam Med. 2012(10)1:34-41.

Purchasing High Performance Update: Medical Homes Gain Momentum
The Commonwealth Fund (2012)

Quality and Equity of Primary Care With Patient-Centered Medical Homes: Results from a National Survey
Medical Care (2012)
This article discusses the results of the 2007/2008 National Survey of Children's Health, that found that having a patient-centered medical home was associated with significantly better performance for 6 of 10 quality-of-care measures using multivariable regression models, adjusting for demographic and socioeconomic covariates of pediatric quality-of-care assessed.

Quality Medical Homes: Meeting Children's Needs for Therapeutic and Supportive Services
Benedict RE. Pediatrics. 2008. 121:1;e127-e134.

A Review of the Evidence for the Medical Home for Children With Special Health Care Needs
Homer CJ, Klatka K, Romm D, Kuhlthau K, Bloom S, Newacheck P, Van Cleave J, Perrin JM. Pediatrics. 2008;122;e922-e937

Strengthening Health Care for Children: Primary Care and the Medical Home. National Business Group on Health (2009)
Center for Prevention and Health Services (2009)

Unmet Dental Care Needs Among Children With Special Health Care Needs: Implications for the Medical Home
Lewis C, Robertson AS, Phelps S. Pediatrics. 2005. 116:3;e426 -e431.

The Value of the Medical Home for Children without Special Health Care Needs
Long WE, Bauchner H, Sege RD, Cabral HJ, Garg A. Pediatrics. 2012;129:1.87-98.

Will the Affordable Care Act Move Patient-Centeredness to Center Stage?
Urban Institute and the Robert Wood Johnson Foundation

For a list of published articles that highlight cost savings associated with medical home implementation, please click here. For information and reports on national demonstration projects and state initiatives, click here.

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