Sources of Quality Indicators

CMSA Glossary of Terms Related Quality Indicators

✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 22, 2025.

CARF: Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.

JCAHO: Joint Commission on Accreditation of Health Care Organizations.

Utilization Review Accreditation Commission (URAC): A not-for-profit organization that provides reviews and accreditation for utilization review services/programs provided by freestanding agencies. It is also known as the American Accreditation Health Care Commission.

Centers for Medicare & Medicaid Services (CMS)

CMS collects and reports quality indicators through numerous programs that address care across the healthcare continuum. These programs encourage the improvement of quality through payment incentives, payment reductions, and quality improvement activities. CMS quality indicators relevant to case management focus on improving patient outcomes, reducing hospital readmissions, and ensuring cost-effective care. These include the Hospital Readmission Reduction Program (HRRP) and the Value-Based Purchasing (VBP) Program.

Utilization Review Accreditation Commission

The Utilization Review Accreditation Commission (URAC) believes that effective case management puts the consumer at the center of all health care decisions and is an essential driver to ensuring that consumers get the right care, in the right setting, at the right time. URAC’s Case Management accreditation allows for the application of case management standards across all health care settings such as medical and social case management, behavioral health providers, hospital case management, disability and workers’ compensation case management, and emerging practices.

URAC’s case management standards cover:

  • Scope of services standard; types of clients served, delivery model for case management services, qualifications for case management staff.
  • Case management staff standard; guidelines for caseload, availability of physician for consultation, a process for training and education of case managers.
  • Case management process standard; criteria for identifying clients for case management services, disclosure to clients the nature or the case management relationship, documentation of consent, policies to document patient assessments, policy for resolving disagreements, criteria for discharge.
  • Organizational ethics and confidentiality standard; policy and procedure to protect confidentiality, promotion of autonomy of decision making, patient input into the case management plan, respecting rights of patient to refuse treatment or services.
  • Complaints standard; policies and procedures for patients and providers to submit a complaint.

National Committee for Quality Assurance

NCQA’s Case Management Accreditation is a comprehensive, evidence-based accreditation program dedicated to quality improvement that can be used for case management programs in provider, payer or community-based organizations.
NCQA’s Case Management Accreditation:

  • Directly addresses how case management services are delivered, not just the organization’s internal administrative processes.
  • Gets right to the core of care coordination and quality of care.
  • Is designed for a wide variety of organizations. It is appropriate for health plans, providers, population health management organizations, and community-based case management organizations.
  • focuses on ensuring the organization has a process to ensure safe transitions.

The standards address how case management programs:

  • Identify people who are in need of case management services;
  • Target the right services to people and monitor their care and needs over time.
  • Develop personalized, patient-centered care plans;
  • Monitor people to ensure care plan goals are reached and to make adjustments as needed;
  • Manage communication among providers and share information effectively as people move between care settings, especially when there are transitions from institutional settings;
  • Build in consumer protections to ensure people have access to knowledgeable, well-qualified case management staff;
  • Keep personal health information safe and secure.

NCQA standards also call for case management program staff to stay up to date on the latest evidence and care management techniques and work towards continuous improvement in patient outcomes and satisfaction.

Healthcare Effectiveness Data and Information Set (HEDIS)

In addition to providing accreditation, NCQA sponsors, supports, and maintains a collection of standardized performance measures known as the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS enables reliable comparisons of healthcare quality across health plans for consumers, purchasers, and regulators.

HEDIS consists of numerous measures in six domains of care:

  1. Effectiveness of care: includes immunization status, screenings for cancers, condition management strategies, and education
  2. Access/availability of care: access to all levels and specialties of care
  3. Experience of care: patient satisfaction with service and care
  4. Utilization and risk-adjusted utilization: procedure frequency, antibiotic stewardship, infection rates, readmissions, emergency department use versus doctor office visits
  5. Health plan descriptive information
  6. Measures collected using electronic clinical data systems: includes screenings for depression, unhealthy alcohol use, and adult immunizations

National Quality Forum

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that’s mission is to improve the quality of healthcare. NQF promotes consensus among a wide variety of stakeholders around specific standards that can be used to measure and publicly report healthcare quality.

NQF has endorsed performance measures that can be used to measure and quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality care. Once a measure is endorsed by NQF, it can be used by hospitals, healthcare systems, and government agencies like the Centers for Medicare & Medicaid Services for public reporting and quality improvement.

NQF Performance Measures:

  • Convenes working groups to foster quality improvement in both public- and private-sectors;
  • Endorses consensus standards for performance measurement;
  • Ensures that consistent, high-quality performance information is publicly available; and
  • Seeks real time feedback to ensure measures are meaningful and accurate.


NQF-endorsed measures are evidence-based and valid, and in tandem with the delivery of care and payment reform, they help:

  • Make patient care safer;
  • Improve maternity care;
  • Achieve better health outcomes;
  • Strengthen chronic care management;
  • Hold down healthcare costs. New directions are further strengthening how we engage with the healthcare community to drive quality improvements.

Agency for Healthcare Research and Quality

AHRQ’s mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used.
AHRQ’s priority areas of focus are:

  • Improve health care quality by accelerating implementation of patient centered outcomes research
  • Increase accessibility to health care
  • Improve health care affordability, efficiency, and cost transparency
  • Make health care safer:

          -Prevent healthcare associated infections
          -Accelerate patient safety improvement in hospitals
          -Reduce harm associated with obstetrical care
          -Improve safety and reduce medical liability
          -Accelerate patient safety improvements in nursing homes

National Quality Strategy (NQS)

The NQS was developed to improve healthcare service delivery, patient outcomes, and population health. It was created with input from stakeholders representing all members of the care continuum, as well as the general public. The NQS is defined by a 3-6-9 strategy, a set of three overarching aims building on the Triple Aim, six priorities of common health concerns, and nine levers to align business/organizational functions and drive quality improvement.

Resources:

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html

http://www.qualityforum.org

http://www.ahrq.gov/about/index.html

This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, purchase your copy at CCMCertificationMadeEasy.com.