The quality of healthcare provided in this country is not optimal. We know this either through personal circumstance or through evidence-based reports, such as the National Healthcare Quality Report published by the Agency for Healthcare Research and Quality. Reports like these highlight the need for improvement of the quality of care in the United States. But how do we improve?
Citing Harvey V. Fineberg, MD, past president of the Institute of Medicine, the “only way to know whether the quality of care is improving is to measure performance” (October 2005). Performance measures are the tools used to define quality and to determine if quality exists by providing information on current and past performance.
Hospitals and other providers measure performance to meet many internal and external demands. For internal improvement efforts, measures assess the strengths and weaknesses of clinical processes and deliver a baseline that can be used for comparison. They provide verification that a quality improvement effort actually works as well as sustains improvements by identifying undesirable changes to processes.
Provider accountability, decision making, public reporting and supporting national priorities are some of the reasons that organizations measure their performance. Purchasers of services are requiring evidence that an organization adds value for consumers. Specifically, they are looking to see if organizations can manage their costs, satisfy their customers, and have favorable patient outcomes (Schmaltz, et al, 2014).
Different types of measures provide different information. Avedis Donabedian, a pioneer in the field of quality, classified measures into three types—structure, process and outcome. Structural measures evaluate resources and/or infrastructure. They ask the question, “Does the organization have the proper foundation to deliver high quality services to patients?”. Examples of this type of measure include staffing levels, facilities and clinician training.
The second, and most prolific measure type are process measures. This type of measure evaluates actions taken by clinicians in the provision of care. They are abundant in healthcare because they provide opportunities for interventions that can result in process improvements. Additionally, they are actionable or under the control of a clinician. An example of a process measure is the percentage of women (ages 21 to 64) who were screened for cervical cancer.
Outcome measures evaluate the results of the treatment or intervention. This measure type is very important to consumers because it relates to survival, unintended effects of treatments, and relief of symptoms. Overall, outcome measures focus on whether the health of an individual has improved after an intervention. An example of an outcome measure is pneumonia mortality (e.g., the percentage of in-hospital deaths per 1,000 discharges with pneumonia as a principal diagnosis for patients ages 18 or older).
Healthcare organizations have a difficult time demonstrating the quality of their services due to the complexities of care. Many organizations have been reluctant in the past to institute quality improvement programs because there was no improved profitability for better quality outcomes. However, with the movement toward value-based payment, organizations have accelerated their efforts to improve. Performance measurement will play a critical role in determining which providers are paid for demonstrating high quality and cost efficiency and which are not.
