Measuring Quality

The National Quality Measures Clearinghouse identifies 2,100 quality indicators, and the Agency for Healthcare Research and Quality (AHRQ) National Healthcare Quality and Disparities Report contain more than 250 indicators. Avedis Donabedian, a pioneer in the study of quality in health care, established the important linkage between structure and process in affecting any outcomes of interest. This concept is still important today and is summarized below:

Structural measures: These metrics look at the attributes of a health care provider organization that would promote quality of care. Examples of these include the physical location, the number of staff members, the use of databases and registries, etc. The primary focus of structural measures is on the organization as opposed to the patient.1

Process measures: These metrics look at the process of care for the patient. They represent the things that are actually ‘done to and with the patient.’ They are rather common and include ordering lab tests (e.g., A1C, blood pressure, and LDL cholesterol tests), conducting eye exams, and measuring BMI.

Outcome measures: These metrics look at the health state of a patient resulting from health care. An outcome measure thus requires data about health states (i.e., states occurring within the body of a patient).1 Mortality and morbidity are classic outcome measure endpoints. Actual lab values, such as an A1C that is less than 7 percent, are intermediate values that are known to impact morbidity and mortality. Outcomes can be viewed in aggregate in disease models to measure long-term outcomes as a surrogate for actual population metrics. The common health risk assessment provides patients with graded opportunities to improve health through risk reduction.1

Patient-reported outcome measures (PROMs): There is increasing interest in PROMs to improve the quality of health care.2 PROMs are any reports coming directly from patients about their health condition and treatment,3 including symptoms, functional status, and health-related quality of life.4 Recent systematic reviews have demonstrated that PROMs can improve patient-clinician communication and the processes of care individual patients, but they have also consistently shown minimal influence on patient outcomes.2 Research into the use of PROMs as quality improvement tools is ongoing and may increasingly guide health care systems in how they approach quality.

Other measures have been recently developed and play an important part in the measurement of quality in health care, including:

  • Value measures: Value is simply defined as the quality of a product over cost. The perceived quality of care allows the consumer to spend more money for the product. In health care, metrics that assess value are often applied to limited use of costly drugs when alternatives are available. The current discussion of the Triple Aim5 has an inherent measure of value.
  • Patient satisfaction measures: These measures are often gathered through a standard questionnaire but may also be gathered through other means of patient feedback. The two most common survey tools are the Consumer Assessment of Healthcare Providers and Systems (CAHPS)6,7 and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).8 As is common in other industries, a measure of patient—or consumer—feedback drives an organization to improve the quality of its services.