If you can’t measure it you can’t change it!

Quality Management leader Peter Drucker coined the phrase “if you can’t measure it, you can’t change it

” to drive home the point, that if we want to improve, we need to know where we are and where we want to go. This has never been as true as it is in the broad healthcare system. As healthcare works to become more patient-centered, with a focus on safety and quality, having a way to measure performance is key.

One method used by today’s health plans to measure quality are HEDIS Measures. The full name for HEDIS is the Healthcare Effectiveness Data and Information Set. HEDIS Measures are viewed as the gold standard in health care performance measurement and are used by more than 90 percent of the nation’s health plans, leading employer groups and regulators to demonstrate the value they bring to those who provide healthcare and health insurance.

HEDIS is a set of standardized measures that specifies how organizations collect, audit and report performance information across the most pressing clinical areas, as well as important dimensions of customer satisfaction and patient experience. For over 17 years, the National Committee for Quality Assurance (NCQA) has worked to build consensus around these measures. As a result of their work, there is a solid process in place that stakeholders can use to measure the health of their populations as well as measure how providers of healthcare services are meeting the diverse needs of their the populations to ensure health and wellness, that span from preventive measures to care provided for prevalent chronic conditions. 

As most healthcare professionals know and consumers are starting to realize, the country’s current trajectory is unstainable. Most realize that we do not have a ‘health’ care system, but a ‘sick’ system. Changing that culture is critical if we want to bend the health cost curve. The best way to change a system is to take the time to collect data, analyze that data and determine results that are good and /or need improvement. Analysis of results may include a review of organizational and provider variables that can have an effect on quality. The HEDIS measures provide a way for all stakeholders to look at results of health promotion, maintenance and restoration efforts by health plans and participating providers.  If there are areas that fall short, e.g. preventive care, chronic illness care that includes diabetes, hypertension, and heart disease, changes can be made in provider and health plan care delivery. When an organization is doing well, they can use this information to promote their organization to current and future customers.

A key need that is taking hold is consumer involvement that has the potential to really bend the cost care curve. To date, consumers have been left out of the process. As a result, costs have spiraled and outcomes are sub-par for many providers and payers. One way to change this is to start to utilize the data being collected by all parties to better educate the consumer, the employer and other stakeholders on how to use quality data and reports.

A first step is to read a report that NCQA puts out annually that addresses the State of Health Care Quality and allows employers, payers, providers and consumers to see who is performing well in various categories, including areas of prevention such as immunizations, mammograms, colon rectal screenings and more. Also included in the report is how organizations are using evidenced- based guidelines to manage patients with chronic disease such as diabetes, congestive heart failure, and pneumonia.

Today, we have the diagnostic tools and resources to treat patients with chronic conditions. But many times providers have not incorporated clinical guidelines into their practice. In addition, we have not taken the time to assess our patients well to understand their goals and ensure that they understand their condition(s) and that the plan of care meets their goals. Including the patient as an active member of the healthcare team is critical for any changes to occur.

Understanding the HEDIS measures is the first step in assisting the employer and the consumer as to where to put their healthcare dollars.  HEDIS data can describe population data and performance of healthcare providers regarding various metrics important to the delivery of quality health care.  Top performing health plans are identified, increasing and competition is increased as health plans better differentiate between care and outcomes that are effected by a network of healthcare providers. It also ensures all stakeholders are focused on providing safe, quality, effective healthcare.  

Professionals who work in the area of quality management are usually the ones who are aware of these measures. If we are going to truly transform the healthcare system so that consumers can be educated, and to ensure that the system is safe, effective and equitable, it is our responsibility to help all participants understand how to use this type of data. In my next few Blog posts, I am going to provide information on HEDIS and share examples of how using HEDIS data can improve services for both payer and provider organization.  If you work in an organization that has been successful in using HEDIS to educate consumers and employers to better understand the health care system, please email me so that I can interview you for an upcoming post. You can reach me at [email protected].

By Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN

Thank you for reading Managed Healthcare Matters. I look forward to your comments and suggestions for topics that you would like to see in future posts.

Reference: To view the 2016 State of the US Healthcare. Click here

Final 2017 HEDIS ratings will posted on NCQA.org on September 20, 2017

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN


Anne is a registered nurse with close to 40 years of experience in the healthcare industry. She holds a Master’s Degree in Training and Development from St. Francis University and a Bachelor in Health Services from Barry University. Anne is a board certified case manager through the American Nurses Credentialing Center and the Commission for Case Manager Certification. She is also a certified registered rehabilitation nurse through the American Rehabilitation Nursing Association. She is past President of the Case Management Society of America and also Governor for District 27 of Quota International. Anne is a frequent speaker both nationally and internationally on issues related to the practice. Anne is a co-author of Case Management Review and Resource Manual: published by the American Nurses Credentialing Center and now in its 3rd edition.

Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced healthcare professionals in managed care and clinical roles for temporary assignments and direct hire opportunities.  Additionally, PSN’s consultants work with organizations and providers seeking accreditation or re-accreditation with URAC or NCQA. For additional information regarding our services contact us at 301-460-4089 or email us at [email protected].