Ideally, performance measures are based on high quality evidence regarding the interventions and services that will achieve desired outcomes and reflect high quality care. As guidelines and performance measures are increasingly used for public reporting and payment, the necessity for a strong evidence base has become more urgent and compelling. To achieve the intended positive effects of quality measurement and minimise potential unintended consequences, measures should be based on the best evidence for the focus of measurement. While outcome measurement is increasingly preferred, many measures continue to focus on process steps distal from the desired outcome, even when there is evidence for a more proximal intervention or intermediate outcome that can be linked to the desired outcome. Guidelines are a critical step in the supply chain to performance measures and ultimately evidence-based improvement processes. The quality of the guideline and the evidence review has significant downstream implications for measure development. The complexity of guidelines may also limit the ability to translate into feasible performance measures. The degree of specificity in the guideline has implications for the precision of the measure specifications. Measurement is impeded by the lack of specificity in guidelines, such as imprecise “high risk” population designations and insufficient information regarding periodicity. Though potentially useful for clinical care, extensive use of exceptions in guidelines makes them difficult to operationalize into measures. To ensure that guidelines can be readily adaptable for performance measurement, greater communication and collaboration is needed between the guideline and measurement communities. Ideally, guidelines would be developed with experts in performance measurement and clinical decision support at the table to ensure that evidence synthesis and guidelines can effectively serve the needs of measurement and improvement.
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