Performance Measurement and Leveraging of Results: Problems and System Goals


Lack of nationally endorsed maternity care performance measures

The National Quality Forum (NQF) is a consensus-based entity that fosters performance measurement. Although the NQF has endorsed 24 measures that apply to maternity care, significant gaps remain for numerous crucial maternity topics. The generic Consumer Assessment of Healthcare Providers and Systems (CAHPS) facility, provider, and health plan surveys do not adequately address important dimensions of maternity care quality.

A comprehensive set of nationally endorsed maternity care performance measures is needed to assess patient experience, outcomes, and other dimensions of quality across the full episode of maternity care and in the various settings where care is received.

Problems with availability of performance measurement data

Many measures of interest for improving maternity care quality cannot be implemented currently because the data needed for measurement are not routinely and systematically collected, and collection would impose an undue burden. The current coding system was designed for billing and has shortcomings when used for performance measurement.

Problems with performance data reporting and use

Public reporting of currently endorsed performance measures is inadequate. Large-scale reporting of maternity care performance has been very limited. Reporting interfaces are not user friendly and comparison at the health professional level is virtually unavailable. The Centers for Medicare and Medicaid Services (CMS) has one of the best-developed public reporting programs through its Hospital Compare websites, but these are Medicare focused, limited to data on hospitals, and do not include maternity care. There is wide variation in performance reporting among states.

Currently endorsed maternity measures focus especially on facilities. This makes it hard to encourage clinician accountability and to help women choose caregivers wisely. Clinicians and facilities generally lack reliable and trusted feedback about their own performance, or the performance of other clinicians and facilities, which can foster quality improvement.

Current maternity measures are not stratified by race/ethnicity, insurance status, socioeconomic status, and language to aid in measuring and reducing disparities, and none directly assess disparities. Many are not risk adjusted, making interpretation of comparisons difficult.

For key measures such as cesarean section and VBAC rates, there is controversy about appropriate threshold rates. Healthy People 2010 has established target cesarean and VBAC rates, and the United Nations recommends a cesarean rate range of 5% to 15%. However, the national cesarean rate reached 31.8% in 2007, and maternity professionals frequently reject targets or ranges. Some reporting systems exclude cesarean rates entirely on the grounds that an optimal rate is not known. Despite the need to move toward an optimal range and reduce harm and expense associated with current trends, existing reporting systems do not give childbearing women and other stakeholders needed guidance.

Childbearing women have not been actively engaged in defining maternity measures that are of greatest interest to them or in testing existing performance reporting systems, which greatly reduces the likelihood that they will see, understand, and use reporting systems.

System Goals

  • A robust, comprehensive system for performance measurement and reporting with mechanisms for ongoing monitoring and refinement improves the quality and outcomes of maternity care.
  • Performance measurement and reporting are grounded in best evidence.
  • Measures are widely applicable and balanced across key criteria. Measures employ appropriate design and analytic methods to ensure fair comparisons of performance and illuminate disparities in risk, outcomes, and health care delivery across populations.
  • There is broad stakeholder participation in the development, implementation, and reporting of maternity care performance measures.


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