Before we revisit Ms. Jones’ story and the coronary artery disease outcomes from ICHOM, let’s define the different types of quality measures.
To improve health care value, there must be an overall measurement strategy in place. Just measuring outcomes is often not enough.
Outcomes depend on many factors within and aside from health services. Even if a patient presenting to an emergency department with a heart attack received “atrocious care,” he still may have a good outcome—if one did nothing for this patient other than provide pain relief, he would still have a 60-70% chance of surviving and being able to resume his daily activities. The patient’s outcome would be considered great, but their care would have been so wasteful as to be appalling.
Conversely, great process compliance ratings can be associated with appalling outcomes.
Ultimately, process analysis and outcome measures are both needed to drive improvement. Outcome measures are needed to know what works. Process measures are needed to know what inputs and activities achieved the result.
Often quality measures are categorized into:
What is actually done in giving and receiving care. For a process measure to be valid, it must previously have been demonstrated to produce a better outcome.
The material, human, and organizational resources available in the settings in which care is delivered.
Efforts to ensure changes do not result in other unintended consequences or effects.
For example, if efforts to discharge patients before noon actually resulted in increased length of stay because some patients were being kept until the next day to be discharged in the morning, this would be an important balancing measure that may not be captured if one is only measuring the percentage of patients discharged prior to noon.
The effects of care on the health status of patients and populations.
For example, if fewer people die after receiving influenza vaccines, then this mortality benefit would be an outcome measure.
Porter & Teisberg, Redefining Health Care, 2006
Most of today’s required “quality” measure are process measures, discussed as if they were outcome measures. Process measures measure what is actually done in giving and receiving care, not the effects of that care. To measure the effects of care, we need outcome measures.
Process measures are easier to track and to control, but have invited a burdensome level of micromanagement for physicians. While every organization needs to track its processes and work to improve them, today’s required reporting of thousands of process measures reduces and, in the view of many physicians, undermines efficiency. Process measures also may fail to capture critical, unarticulated reasons why the care worked.
The thing to remember is that absent measured outcomes, no one really knows which processes are better – which processes improve quality of life and dignity of death for patients.
For this reason, processes and outcomes are part of a continuum that connects the inputs and outputs of health care delivery and thus are best used in combination.
The outcomes that matter most to a segment of patients with shared needs or conditions are usually a small subset of that list. Attention to a parsimonious set of meaningful outcomes is the most powerful accelerator of learning and improvement.
