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Thursday, November 7th 2002

Kenneth W. Kizer, MD, MPH
President and Chief Executive Officer
National Quality Forum
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Suite 500 North
Washington, DC 20005

Dear Dr. Kizer: 

The American Hospital Association (AHA), on behalf of its nearly 5,000 member hospitals, health systems, networks, and other providers of care, appreciates the opportunity to comment on the draft report on the National Quality Forum’s (NQF) draft document, A Comprehensive Framework for Hospital Care Performance Evaluation.   This document undertakes the very difficult task of trying to create a framework for measuring and reporting information on the quality of hospital care.  While we recognize the hard work of the staff and the Steering Committee to propose a comprehensive hospital measurement framework, the document as written falls short of delineating a complete framework and structure for hospital measurement. 

Framework documents should include the conceptual foundation for further work, the dimensions of what is to be included and excluded, and the key characteristics of the final product.  A good example of such a framework was the Institute of Medicine’s (IOM) report Envisioning the National Quality Report.  This hospital measurement framework does not clearly describe what a set of hospital measures would be, nor does it clearly identify the key characteristics of the set of measures as a whole.  Our comments can be summarized in five points:

1)     Key pieces of the framework are missing.

·        We believe that the intention of the Steering Committee was to create a framework that could be described using the six aims for health care from the IOM’s report Crossing the Quality Chasm, some priority conditions, and other facets of health care.  Nowhere in this document is that conceptual structure described.  It must be clearly articulated.

·        A description is needed of the characteristics of the set of measures.  The document as written provides no information about what the Steering Committee proposes the measure set as a whole should look like.

In Attachment A, we have provided an outline for reconstructing the document to include these important issues. 

2)     Other elements should be deleted.  Included in this document are recommendations for NQF members’ responsibilities in advocating NQF consensus measures, instructions for measure developers and for those creating quality reports, and other topics.  These items are inappropriate in a framework document on hospital measurement and should be eliminated.  In Attachment B, we have provided specifics on the items that should be eliminated.

3)     The competing nature among measures should be described and recommendations included about how to balance these interests.  In the comments about the initial set of hospital core measures, different members placed different levels of importance on the criteria for choosing measures.  For example, the desire for scientific integrity of the measures may seem more important to some, while the need to make more information available rapidly may carry greater weight with others.  The importance of making a lot of information available across a wide variety of conditions may be of great importance to some, while others may be focused on minimizing the reporting burden and maximizing attention to a few important opportunities for improvement. 

      For the National Quality Forum to work well, its members need to discuss these important priorities and develop a common understanding of how they can be balanced.  This framework document is precisely the kind of document that could spark such a discussion.  To do so, the reasons for each criterion should be made clear in the document.  Likewise, the imperatives for achieving some sort of balance among the different criteria must be discussed.  Then, this document would provide the basis for a thoughtful debate among the members, which is what the Provider and Health Plan Council and Research and Quality Improvement Council called for at the recent NQF annual meeting.  Further, it would enrich the understanding of those who seek to use the NQF measures and framework. 

4)     Other NQF work products should be integrated into the hospital measurement and reporting framework.  This document is written as if the hospital core measures stand alone in hospital quality assessment.  But the Safe Practices report, the Serious Reportable Events, the Nursing Home Measures for institutions that have skilled nursing facility beds, the diabetes measures, and other measures that may soon be produced by the NQF on cancer care and cardiac care quality, all must be included in the framework. 

We look forward to further discussions with staff and other members about this document and its implications for the work of the National Quality Forum.  Please contact me or Nancy Foster, senior associate director for policy, at 202-626-2337 if we can be of further assistance.


Rick Pollack
Executive Vice President

Attachments A and B


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