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Another approach would be to compare scores to an independent standard of what performance on this measure ideally should be. While implementing this approach is challenging, it has significant advantages.

Advantages of Comparing to an Independent Standard

• It sets the highest appropriate bar.
• It tells people exactly what performance should be.
• The comparator remains the same over time.
• It emphasizes having everyone try to reach for the standard instead of just trying to be as good or better than other local plans or providers; this may encourage collaborative quality improvement efforts.
• If local providers are far from the target, this might lead policymakers such as payers, legislators, or regulators to take steps to encourage better performance or make it easier to achieve.

Disadvantages of Comparing to an Independent Standard

• Independently developed, defensible standards exist for only a few quality measures.
• While it might be possible to have stakeholders in the community or State come up with such standards, their standards might not be as credible as, for example, ones developed by a major professional association or specialty society. This process would also take considerable time and effort.

The Standard for “Never Events”

There is one kind of standard that is beginning to emerge in health care: the standard of “never” or zero percent for certain adverse and preventable events. While “zero-tolerance” is implied by the term “never event,” this may not be language that the public understands unless it is carefully defined. Don’t assume that consumers will understand that the standard for these measures is zero; make it explicit by saying something like “Look for a provider whose score on this measure is zero. These events are preventable and should never happen.”