Populations of Focus

People with Behavioral Health Conditions Guide

Version 3 – June 2026

APPENDIX C:

C: Developing a Robust Measurement Strategy

 

FIGURE 15: DEVELOPING YOUR MEASUREMENT STRATEGY MILESTONES

Figure 15 illustrates the key milestones in the development of a robust measurement strategy.

Phmi Measurementstrategymilestones

 

FIGURE 16: DEFINITION AND EXAMPLES FOR MEASUREMENT STRATEGY MILESTONES

Figure 16 provides guidance on each of these milestones as you work to put in place a robust yet practical measurement strategy to improve outcomes for adolescents and adults with behavioral health needs.


Milestone
Definition
Example for Adults with Behavioral Health Conditions

Aim(s)

The overall goal(s) of the improvement effort. “What are we trying to accomplish?”

We often recommend sub-aims to focus your team on intermediate goals. You can develop data-informed specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals focused on improving specific aspects of care for attributed patients or subpopulations of patients.

Overall aim: People who are struggling with depression receive appropriate care that fits their needs.

Example sub-aim: By December 2025, we will increase the percent of Black and Hispanic or Latino/a patients aged 12 and older who had a depression screen in the last 12 months from 59% to 95%.

Concept(s)
A general, abstract notion (e.g., approach, thought, belief, or perception) related to the aim(s) of focus.

Measures

Specific, objective ways to determine the extent to which an aim has been met or to determine if there has been improvement in the concepts of focus. Measures help us to answer the question, “How will we know that a change is an improvement?” Measures generally fall into one of three types:

  • Outcome measures: Measure the performance of the system(s) of focus and always relate directly to the aim(s). Outcome measures are focused on the end results and offer evidence that changes are actually having an impact at the system level.
  • Process measures: Pertain to the activities, steps or actions taken within the system(s) of focus that are believed to be most related to improving the outcome(s) of focus. These measures help evaluate efficiency, effectiveness and consistency. Process measures are essential for understanding how well the system is working and can be early indicators of improvement
  • Balancing measures: Look at a system from different directions or dimensions, including the effects a change may have on other parts of the system. This also includes a way of measuring unintended consequences or effects further upstream or downstream.

See below for example outcomes, process and balancing measures.

For the following examples, we will examine the percentage of people aged 12 and up who were screened for depression using a standard screening tool and, if positive, received follow-up care within 30 days.

Operational definitions
A detailed description in quantifiable terms of what to measure and the steps to follow to measure it consistently each time and over time. The operational definitions help make the measure clear and unambiguous and often contain criteria for inclusion or exclusion and numerator/denominator.

Depression screening: Percentage of people aged 12 and older who were screened for depression using a standard screening tool and, if positive, received follow-up care within 30 days. The CMS specifications of this measure are available here.

Data collection plan

A detailed set of instructions that generally includes:

  • Who (specifically) will collect the data.
  • How (specifically) the data will be collected.
  • Where and how the data will be stored.
  • When the data will be collected.
  • How often (e.g., frequency) the data will be collected.

Depression screening data collection plan:

Who:

  • Reception staff with medical assistant.

How:

  • Reception staff hands out questionnaire upon check-in; MA enters results into the EHR when rooming.

Where and how the data will be stored:

  • Within the patient record in a field where data can be pulled for an automated report.

When the data will be collected:

  • Data will be collected during patient visits (when indicated on the care gap report).
  • Follow-ups should be documented within the EHR as appropriate.

How often:

  • Reports to evaluate improvement of the practice as a whole will occur on a quarterly basis.

Data collection
The process of collecting the agreed upon measures in accordance with the relevant operational definitions and the agreed upon data collection plan.

Analysis and action
The process of analyzing the data, including instructions for the analysis and visualization of the data, disseminating the data to relevant parties, and using the data to track progress and guide improvement efforts.
Depression screening analysis and action:
During the improvement period, the QI team reviews data on a weekly basis. The care team and panel manager review the data subsequently once per quarter for ongoing monitoring.

 

Creating a SMARTIE goal

A SMARTIE goal is important because it clearly states a purpose or direction, ensures everyone is on the same page, and sets a realistic target, all while ensuring the outcome is equitable and inclusive. The template below can help your team ensure your goals are SMARTIE.

MAKE IT SMARTIE

  • Specific: Use explicit language that details the intended outcome of your change initiative.
  • Measurable: Quantitatively define what success will look like by using baseline data and stating the intended outcome to facilitate progress tracking.
  • Achievable/Ambitious: Consider what you can achieve in 2026 and how much you want to stretch your team and organization in achieving the goal.
  • Relevant: Explain who or what the project will impact (e.g., specific population) and provide a rationale for why this is important.
  • Time-bound: Establish a date or period by which you want to accomplish the goal (include a specific date).
  • Inclusive: Bring the people who are most impacted into processes, activities, and decision making in a way that shares power (this may be reflected in how you implement the goal).
  • Equitable: Seek to address systemic injustice or inequity.

SMARTIE GOAL TEMPLATE

Improve / Increase / Reduce _____________________________ (specific measure, e.g., vaccine completion rate) of/for ______________ (add population / subpopulation or area of focus – e.g., children between 0-2 years of age) from ___________ (baseline) to ______________ (target goal) by _________ (specific date within 2026).

EXAMPLE

By 12/31/2026, the primary care team will increase the rate of universal depression screening (using the PHQ-9) for adults aged 18+ from 60% to 85%, while ensuring that 80% of patients with a score of 10 or higher have a documented follow-up plan initiated during the same visit.

 

POPULATION HEALTH GUIDE FOR UNDERTAKING 3 PART DATA REVIEW

The three part data review is a tool that can be used to advance work related to population health. It draws on asset-based inquiry, to surface to identify needs and opportunities to understand the ways in which systems have discarded or undervalued the assets of individuals and communities. Groups can then work together to ensure that all can contribute to advancing population health and well-being and dismantling inequities. Access the full resource.