In general, quality of clinical care is assessed by asking the following questions:

A standard of care for a particular episode of illness would answer the questions:

Measures would include:

NP performance is evaluated on several levels: productivity, utilization, and patient satisfaction, as well as quality of clinical decision making. An NP’s performance is going to be judged by employers, patients, health plan auditors, peers, and possibly researchers.

If an NP’s performance is employer defined, then the NP will need to ascertain the values of the employer. To one employer, good performance might be high billings, which could, by nature of time constraints, preclude much time and attention given each patient. For another employer, good performance might be high scores on surveys of patient satisfaction. An NP who satisfies patients might not be a high biller. To yet another employer, good performance might be close communication with the physician consultant. To another, it might be independent functioning without need for communication with a physician.

If performance is defined by the health plan, then a good performer is one who uses expensive resources—hospitals and emergency rooms—relatively infrequently.

If an NP’s performance is defined by present performance measures developed by consumer-oriented groups, such as NCQA, an NP who sees that all children are properly immunized, who gets patients to quit smoking, and who raises the functional status of elderly patients will be a good performer.

If an NP’s performance is defined by peers, a good performer will be one who is an expert diagnostician and who shares knowledge willingly with other NPs.

If performance is defined by researchers, a good performer is one who meets the particular testing criteria studied by the researcher.

If performance is defined by patients, a good performer is one who did not make the patient wait more than 20 minutes in the waiting room before being seen, who is patient and polite, and who does not miss a serious diagnosis.There is no single, widely accepted set of measures of an NP’s worth or performance. In this chapter, several measures of performance are summarized.

A definition of productivity may depend upon the setting and the method of payment to the practice.

In a practice that gets reimbursed according to fee-for-service, a productive NP will be one who sees many patients, at a 99213 level or above, and who bills often for additional services that bring revenue, such as suturing, incision and drainage, and endometrial biopsy.

In a practice that receives mostly capitated payments, then an NP who efficiently handles a large panel of patients with little use of the practice’s resources—staff, materials, time—will be a good performer.

If an NP is employed by a nursing home, productivity may mean keeping elderly patients out of the hospital, while imparting to their families the feeling that their loved one is being closely monitored and well cared for.

In a fee-for-service practice, a simple way of measuring performance would be to set the number of visits conforming to the evaluation and management Current Procedural Terminology (CPT) codes. For example, good performance could be set at 20 visits at levels 99211 to 99215 per day. One would not want to set a specific code as a performance measure because it is the patient’s need for evaluation and management services that determines the CPT code billed, and a provider cannot predict what level of visit will be needed.

In a capitated practice, good performance could be set at maintenance of an 1800 member panel of patients, with patient satisfaction, as measured by a particular tool, at 80% or above.

In a nursing home practice, good performance could be measured by decreasing, over a previous year, the number of hospital visits among the nursing home’s residents.

For a detailed discussion of NP productivity, see “Productivity Incentive Plans for Nurse Practitioners: How and Why” by Carolyn Buppert at http://www.buppert.com.

NPs may have more experience with “housekeeping” forms of performance measurement than with substantive forms like Physician Quality Report System or HEDIS measures. For example, many NPs’ charts are audited for such things as clear labeling of allergies, laboratory results initialed and dated, name of patient on every page, and problem list filled in. These are important matters.

In the future, however, NPs should expect that audits will become more and more oriented towards outcomes.

Nonclinicians have begun to get involved in measurement of clinical performance. After putting out a call for performance measures, NCQA received 800 suggestions and developed HEDIS and a set of clinical performance measures aimed largely at primary care providers. Presumably HEDIS is some indication of what employers, consumers, and health plan executives think is important for healthcare providers to accomplish.

The HEDIS measures are still being refined.

Among the evaluation measures set by HEDIS for primary care providers are:

Some of these data are collected from Center for Medicare and Medicaid Services (CMS) 1500 (billing) forms. Other data are collected by auditors who review charts.

HEDIS also looks at:

HEDIS measures change from time to time. For the current measures and benchmarks, visit http://web.ncqa.org.¹

HEDIS is not the only set of performance measures, and NCQA is not the only organization looking after consumer interests and rating health plans and providers. Among the other organizations publishing performance measures are the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), certain managed care plans, certain state health departments, and AHRQ. The performance measures advocated by these organizations overlap to some extent.

Researchers who have studied NP performance and compared it with physicians’ performance have looked at the following measures: