There is a great deal of pressure for public accountability of health care organizations and individual physicians from purchasers, legislators, and consumer advocates calling for public disclosure of health care outcomes. It is hoped that the comparative information will be used in choosing providers and thereby will force attention to quality issues.
Measurement is critical to quality improvement, but it can sometimes be counterproductive to mix measurement for accountability or research with measurement for improvement [1]. Healthcare organizations often embark simultaneously on a program of guideline implementation (quality improvement) and a program of performance reporting to outside agencies. Commonly the measurement activities needed to support these two programs are conceived as a single endeavour. A unified series of sampling procedures, data collection routines, and data display methods is anticiapted to meet both the improvement and the external reporting needs. This approach, while appealing for its apparent efficiendy, is a pitfall.
Quality Improvement: measurements collected typically are not useful for external reporting and, if used for external reporting, may poison the improvement effort. As they increasingly strive for both accountability and improvement, plans need to be very sensitive to the risk that those groups will be forced to game
their data rather than collect data to be used for real improvement.
Characteristics of Measurement for Improvement
There are at least three steps in process improvement where measurement is likely to be important.
- Identify which problems, or opportunities for improvement need attention.
- Obtaining baseline measurements. Data about the current care process are collected for several reasons:,
- To better understand the extent and nature of the problem
- To provide motivation to change by documenting the extent of the problem
- To provide points of comparison with remeasurements obtained after changes are made
- After a new and improved process has been implemented, to learn the extent to which the new process is being used and what the impact has been on patients, clinic personnel, and costs.
Contrast with Measurement for Accountability
Data for accountability, which are data on outcomes or results, do not usually illuminate how the outcomes were achieved or how processes might be changed to improve the outcomes. The measures selected for accountability will be measures that matter to external parties, for example, outcome data on complication rates or costs of care. However, since these these will be difficult to measure, a surrogate (for example, patient satisfaction with treatemnt) may be used instead. Thus there is a tendency for the data to become more and more remote from data that might be used to change processes of care.
Because data for accountability are intended to reveal and to compare the performance of health care institutions, they must be precise, reliable, and valid. These requirements have several consequences.
- The samples must be sufficiently large to achieve the desired precision. It may be difficult to obtain enough cases to describe small- to medium-sized medical groups, and it will rarely be possible to provide enough data about an individual clinic site.
- To obtain a sufficient sample size, data must often be collected for long periods, with the consequence that the time the data are available, the processes that produced the results have changed.
- Since comparison across different organizations is essential in measuring for accountability, many factors affecting the comparative performance of different institutions must be measured and taken into account in reporting the results; for example, the severity or population differences.
This measurement of potential confounders results in substantial complexity, increasing the cost and delaying the output.
| Improvement | Accountability | Research | |
|---|---|---|---|
| Who? | |||
| Audience (Customers) |
Medical group | Purchasers | Science community |
| Quality improvement team | Payers | General public | |
| Providers and staff | Patients/members | Users (clinicians) | |
| Administrators | Purchasers | ||
| Why? | |||
| Purpose | Understanding of a.process b.customers |
Comparison | New knowledge without regard for its applicability |
| Motivation and focus | Basis for choice | ||
| Baseline | Reassurance | ||
| Evaluation of changes | Spur for change | ||
| What? | |||
| Scope | Specific to an individual medical site and process |
Specific to an individual medical group and process |
Universal though often limited generalizability |
| Measures | Few Easy to collect Approximate |
Very few Complex collection Precise and valid |
Many Complex collection Very precise and valid |
| Time period | Short, current | Long, past | Long, past |
| Confounders | Consider but rarely measure | Describe and try to measure | Measure or control |
| How? | |||
| Measures | Internal and at least involved in the selection of measures |
External | External and usually prefer to control both process and collection |
| Sample size | Small | Large | Large |
| Collection process | Simple and requires minimal time, cost, and expertise. Usually repeated |
Complex and requires moderate effort and cost |
Extremely complex and expensive. May be planned for several repeats. |
| Need for confidentiality |
Very high (Organization and people) |
None for objects of comparison — the goal is exposure |
High; especially for the individual subjects |
| Acute Myocardial Infarction | |||
| 1. | AMI-1 | Aspirin on arrival | |
| 2. | AMI-2 | Aspirin prescribed at discharge | |
| 3. | AMI-3 | ACEI or ARB for LVSD on discharge | |
| 4. | AMI-5 | Beta blocker prescribed at discharge | |
| 5. | AMI-7a | Fibrinolytic therapy received within 30 minutes of hospital arrival | |
| 6. | AMI-8a | Primary PCI received within 90 minutes of hospital arrival | |
| Heart Failure | |||
| 7. | HF-3 | ACEI or ARB for LVSD on discharge | |
| Pneumonia | |||
| 8. | PN-2 | Pneumococcal pneumonia | |
| 9. | PN-3b* | For patients with blood cultures performed in the ED, cultures are done prior to initial antibiotic received | |
| 10. | PN-6 | Initial antibiotic selection for CAP in immunocompetent patient | |
| 11. | PN-7 | Influenza vaccination | |
| Surgical Care Improvement Project | |||
| 12. | SCIP-Inf-1a | Prophylactic antibiotic received within 1 hour prior to surgical incisioon | |
| 13. | SCIP-Inf-2a | Prophylactic antibiotic selection for surgical patients | |
| 14. | SCIP-Inf-3a | Prophylactic antibiotic discontinued within 24 hours after surgery | |
| 15. | SCIP-Inf-4 | Cardiac surgery patients with controlled 6 a.m. postoperative blood glucose | |
| 16. | SCIP-Inf-6 | Surgery patients with appropriate hair removal | |
| 17. | SCIP-Card-2 | Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period | |
| 18. | SCIP-VTE-1 | Surgery patients with recommended venous thromboembolism prophylaxis ordered | |
| 19. | SCIP-VTE-2 | Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery | |
| Children's Asthma Care | |||
| 20. | CAC-1a | Relievers for inpatient asthma | |
| 21. | CAC-2a | Systemic corticosteroids for inpatient asthma | |
| 22. | CAC-3 | Home management plan of care document given to patient/careguver | |
References
- Solberg L I, Mosser G, McDonald S. The Three Faces of Performance Measurement: Improvement, Accountability, and Research www.jointcommissionjournal.com/article/S1070-3241(16)30305-4/pdf
- Chassin MR, Loeb JM, Schmaltz SP, Wachter R. Accountability measures — using measurement to promote quality improvement. N Engl J Med. 2010;363(7):683-8.
- Ash E. The A list: 6 steps to accountability in your business eveash.com