Performance improvement
✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 22, 2025.
Performance improvement focuses on a healthcare organization’s functions and processes and their effect on desired outcomes and meeting clients’ needs.
Performance improvement measures usually fall into one of three categories:
- Process – Measuring how care is delivered, including timeliness, appropriateness, and completeness. Examples include the percentage of clients receiving medication reconciliation at care transitions and the percentage of clients receiving follow-up contact after hospital discharge.
- Structure – Assessing the organization’s setting and systems, including resources, policies, and staff qualifications. Examples include the size of the case manager caseload and the percentage of case managers with certification.
- Outcomes – Measuring the results of healthcare interventions, including changes in health status, knowledge, behaviors, and satisfaction. Examples include hospital readmission rates and patient satisfaction scores.
Quality indicators
Quality indicators are metrics for assessing and monitoring the quality and outcomes of care and services. To be effective, indicators must be measurable, meaningful, and manageable. They should focus on high-volume, high-risk, or problem-prone areas where improvement will significantly impact client care outcomes.
Indicators themselves do not provide definitive answers. Instead, they suggest good quality care or potential problems. They provide a quantitative starting point for quality improvement and prioritization in the healthcare system by identifying potential quality concerns, identifying areas requiring further investigation, and tracking changes over time. Measuring and monitoring of quality indicators can serve many purposes, including:
- Documenting quality care
- Comparing care over time
- Comparing care between places (e.g., geographic regions, hospitals)
- Supporting accountability, such as accreditation and/or regulation
- Supporting quality improvement projects
Indicators of importance to case management
Utilization indicators
Utilization indicators measure how healthcare resources are used and whether they are used effectively. By monitoring these indicators, case managers can identify areas for improvement in resource allocation and care coordination. Examples of utilization indicators include:
- Length of stay (LOS) – Measures the average duration of hospitalization for a given diagnosis, compared to the expected LOS
- Readmission rates – Examines the percent of patients readmitted within a specific timeframe, indicating the effectiveness of discharge planning and follow-up care
- ED utilization: Counts the number of ED visits per 1,000 members, an indicator for the quality of outpatient management
Clinical indicators
Clinical indicators measure the quality of care and clinical outcomes. They help case managers evaluate the effectiveness of a care plan and interventions. Examples include:
- Blood pressure control rates in hypertensive clients
- Pain management scoring in an acceptable range
- Wound healing rates
Productivity indicators
Productivity indicators and measurements evaluate the efficiency and workload management of case managers. Examples include:
- Caseload management – Number of active clients assigned, new clients assigned/enrolled, client contact rate
- Response time – Time from identifying a need to intervention, time to respond to outreach, time to enrollment
- Goal achievement – Percent of client goals achieved
Financial indicators
Financial indicators assess the financial effectiveness of care coordination. Examples include:
- Cost per case
- Avoidable or unreimbursed days
- Denials (by reason for denial, such as administrative, medical necessity, timely filing, failure to notify)
Client experience of care
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced “H-caps”) is a nationally standardized hospital survey of patients’ perspectives of their hospital experience, developed by CMS. Although CMS requires hospitals to administer the survey, it is not given only to Medicare beneficiaries. The survey is administered to a random sample of adult patients across medical conditions.
The Deficit Reduction Act of 2005 requires hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions to collect and submit HCAHPS data to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures, including the HCAHPS survey, may receive a reduced payment. Non-IPPS hospitals, such as critical access hospitals, may voluntarily participate in HCAHPS. The Affordable Care Act also included HCAHPS among the measures used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program.
