The field of quality measurement in healthcare has developed considerably in the past few decades and has attracted growing interest among researchers, policy-makers and the general public (Papanicolas & Smith, 2013; EC, 2016; OECD, 2019). Researchers and policy-makers are increasingly seeking to develop more systematic ways of measuring and benchmarking quality of care of different providers. Quality of care is now systematically reported as part of overall health system performance reports in many countries, including Australia, Belgium, Canada, Italy, Mexico, Spain, the Netherlands, and most Nordic countries. At the same time, international efforts in comparing and benchmarking quality of care across countries are mounting. The Organisation for Economic Co-operation and Development (OECD) and the EU Commission have both expanded their efforts at assessing and comparing healthcare quality internationally (Carinci et al., 2015; EC, 2016). Furthermore, a growing focus on value-based healthcare (Porter, 2010) has sparked renewed interest in the standardization of measurement of outcomes (ICHOM, 2019), and notably the measurement of patient-reported outcomes has gained momentum (OECD, 2019).

The increasing interest in quality measurement has been accompanied and supported by the growing ability to measure and analyse quality of care, driven, amongst others, by significant changes in information technology and associated advances in measurement methodology. National policy-makers recognize that without measurement it is difficult to assure high quality of service provision in a country, as it is impossible to identify good and bad providers or good and bad practitioners without reliable information about quality of care. Measuring quality of care is important for a range of different stakeholders within healthcare systems, and it builds the basis for numerous quality assurance and improvement strategies discussed in Part II of this book. In particular, accreditation and certification (see Chapter 8), audit and feedback (see Chapter 10), public reporting (see Chapter 13) and pay for quality (see Chapter 14) rely heavily on the availability of reliable information about the quality of care provided by different providers and/or professionals.Quality Performance Measure in Health Sciences and Medicine Essay.  Common to all strategies in Part II is that without robust measurement of quality, it is impossible to determine the extent to which new regulations or quality improvement interventions actually work and improve quality as expected, or if there are also adverse effects related to these changes.

This chapter presents different approaches, frameworks and data sources used in quality measurement as well as methodological challenges, such as risk-adjustment, that need to be considered when making inferences about quality measures. In line with the focus of this book (seeChapter 1), the chapter focuses on measuring quality of healthcare services, i.e. on the quality dimensions of effectiveness, patient safety and patient-centredness. Other dimensions of health system performance, such as accessibility and efficiency, are not covered in this chapter as they are the focus of other volumes about health system performance assessment (see, for example, Smith et al., 2009; Papanicolas & Smith, 2013; Cylus, Papanicolas & Smith, 2016). The chapter also provides examples of quality measurement systems in place in different countries. An overview of the history of quality measurement (with a focus on the United States) is given in Marjoua & Bozic (2012). Overviews of measurement challenges related to international comparisons are provided by Forde, Morgan & Klazinga (2013) and Papanicolas & Smith (2013). Quality Performance Measure in Health Sciences and Medicine Essay.

3.2. How can quality be measured? From a concept of quality to quality indicators

Most quality measurement initiatives are concerned with the development and assessment of quality indicators (Lawrence & Olesen, 1997; Mainz, 2003; EC, 2016). Therefore, it is useful to step back and reflect on the idea of an indicator more generally. In the social sciences, an indicator is defined as “a quantitative measure that provides information about a variable that is difficult to measure directly” (Calhoun, 2002). Obviously, quality of care is difficult to measure directly because it is a theoretical concept that can encompass different aspects depending on the exact definition and the context of measurement.

Chapter 1 has defined quality of care as “the degree to which health services for individuals and populations are effective, safe and people-centred”. However, the chapter also highlighted that there is considerable confusion about the concept of quality because different institutions and people often mean different things when using it. To a certain degree, this is inevitable and even desirable because quality of care does mean different things in different contexts. However, this context dependency also makes clarity about the exact conceptualization of quality in a particular setting particularly important, before measurement can be initiated.

In line with the definition of quality in this book, quality indicators are defined as quantitative measures that provide information about the effectiveness, safety and/or people-centredness of care.Quality Performance Measure in Health Sciences and Medicine Essay.  Of course, numerous other definitions of quality indicators are possible (Mainz, 2003; Lawrence & Olesen, 1997). In addition, some institutions, such as the National Quality Forum (NQF) in the USA, use the term quality measure instead of quality indicator. Other institutions, such as the NHS Indicator Methodology and Assurance Service and the German Institute for Quality Assurance and Transparency in Health Care (IQTIG), define further attributes of quality indicators (IQTIG, 2018; NHS Digital, 2019a). According to these definitions, quality indicators should provide:

1. a quality goal, i.e. a clear statement about the intended goal or objective, for example, inpatient mortality of patients admitted with pneumonia should be as low as possible;
2. a measurement concept, i.e. a specified method for data collection and calculation of the indicator, for example, the proportion of inpatients with a primary diagnosis of pneumonia who died during the inpatient stay; and
3. an appraisal concept, i.e. a description of how a measure is expected to be used to judge quality, for example, if inpatient mortality is below 10%, this is considered to be good quality.

Often the terms measures and indicators are used interchangeably. However, it makes sense to reserve the term quality indicator for measures that are accompanied by an appraisal concept (IQTIG, 2018). This is because measures without an appraisal concept are unable to indicate whether measured values represent good or bad quality of care. For example, the readmission rate is a measure for the number of readmissions. However, it becomes a quality indicator if a threshold is defined that indicates “higher than normal” readmissions, which could, in turn, indicate poor quality of care. Another term that is frequently used interchangeably with quali ty indicator, in particular in the USA, is quality metric. However, a quality metric also does not necessarily define an appraisal concept, which could potentially distinguish it from an indicator.Quality Performance Measure in Health Sciences and Medicine Essay.  At the same time, the term qua l ity metric is sometimes used more broadly for an entire system that aims to evaluate quality of care using a range of indicators.

Operationalizing the theoretical concept of quality by translating it into a set of quality indicators requires a clear understanding of the purpose and context of measurement. Chapter 2 has introduced a five-lens framework for describing and classifying quality strategies. Several of these lenses are also useful for better understanding the different aspects and contexts that need to be taken into account when measuring healthcare quality. First, it is clear that different indicators are needed to assess the three dimensions of quality, i.e. effectiveness, safety and/or patient-centredness, because they relate to very different concepts, such as patient health, medical errors and patient satisfaction.

Secondly, quality measurement has to differ depending on the concerned function of the healthcare system, i.e. depending on whether one is aiming to measure quality in preventive, acute, chronic or palliative care. For example, changes in health outcomes due to preventive care will often be measurable only after a long time has elapsed, while they will be visible more quickly in the area of acute care. Thirdly, quality measurement will vary depending on the target of the quality measurement initiative, i.e. payers, provider organizations, professionals, technologies and/or patients. For example, in some contexts it might be useful to assess the quality of care received by all patients covered by different payer organizations (for example, different health insurers or regions) but more frequently quality measurement will focus on care provided by different provider organizations. In international comparisons, entire countries will constitute another level or target of measurement. Quality Performance Measure in Health Sciences and Medicine Essay.

In addition, operationalizing quality for measurement will always require a focus on a limited set of quality aspects for a particular group of patients. For example, quality measurement may focus on patients with hip fracture treated in hospitals and define aspects of care that are related to effectiveness (for example, surgery performed within 24 hours of admission), safety (for example, anticoagulation to prevent thromboembolism), and/or patient-centredness of care (for example, patient was offered choice of spinal or general anaesthesia) (Voeten et al., 2018). However, again, the choice of indicators – and also potentially of different appraisal concepts for indicators used for the same quality aspects – will depend on the exact purpose of measurement.

3.3. Different purposes of quality measurement and users of quality information

It is useful to distinguish between two main purposes of quality measurement: The first purpose is to use quality measurement in quality assurance systems as a summative mec h anism for external accountability and verification. The second purpose is to use quality measurement as a formative mechanism for quality improvement. Depending on the purpose, quality measurement systems face different challenges with regard to indicators, data sources and the level of precision required.

Table 3.1 highlights the differences between quality assurance and quality improvement (Freeman, 2002; Gardner, Olney & Dickinson, 2018). Measurement for quality assurance and accountability is focused on identifying and overcoming problems with quality of care and assuring a sufficient level of quality across providers. Quality assurance is the focus of many external assessment strategies (see also Chapter 8), and providers of insufficient quality may ultimately lose their licence and be prohibited from providing care. Quality Performance Measure in Health Sciences and Medicine Essay. Assuring accountability is one of the main purposes of public reporting initiatives (see Chapter 13), and measured quality of care may contribute to trust in healthcare services and allow patients to choose higher-quality providers.

Table 3.1

The purpose of quality measurement: quality assurance versus quality improvement.

Quality measurement for quality assurance and accountability makes summative judgements about the quality of care provided. The idea is that “real” differences will be detected as a result of the measurement initiative. Therefore, a high level of precision is necessary and advanced statistical techniques may need to be employed to make sure that detected differences between providers are “real” and attributable to provider performance. Otherwise, measurement will encounter significant justified resistance from providers because its potential consequences, such as losing the licence or losing patients to other providers, would be unfair. Appraisal concepts of indicators for quality assurance will usually focus on assuring a minimum quality of care and identifying poor-quality providers. However, if the purpose is to incentivize high quality of care through pay for quality initiatives, the appraisal concept will likely focus on identifying providers delivering excellent quality of care. Quality Performance Measure in Health Sciences and Medicine Essay.

By contrast, measurement for quality improvement is change oriented and quality information is used at the local level to promote continuous efforts of providers to improve their performance. Indicators have to be actionable and hence are often more process oriented. When used for quality improvement, quality measurement does not necessarily need to be perfect because it is only informative. Other sources of data and local information are considered as well in order to provide context for measured quality of care. The results of quality measurement are only used to start discussions about quality differences and to motivate change in provider behaviour, for example, in audit and feedback initiatives (see Chapter 10). Freeman (2002) sums up the described differences between quality improvement and quality assurance as follows: “Quality improvement models use indicators to develop discussion further, assurance models use them to foreclose it.”

Different stakeholders in healthcare systems pursue different objectives and as a result they have different information needs (Smith et al., 2009; EC, 2016). For example, governments and regulators are usually focused on quality assurance and accountability. They use related information mostly to assure that the quality of care provided to patients is of a sufficient level to avoid harm – although they are clearly also interested in assuring a certain level of effectiveness. By contrast, providers and professionals are more interested in using quality information to enable quality improvement by identifying areas where they deviate from scientific standards or benchmarks, which point to possibilities for improvement (see Chapter 10). Quality Performance Measure in Health Sciences and Medicine Essay. Finally, patients and citizens may demand quality information in order to be assured that adequate health services will be available in case of need and to be able to choose providers of good-quality care (see Chapter 13). The stakeholders and their purposes of quality measurement have, of course, an important influence on the selection of indicators and data needs (see below).

While the distinction between quality assurance and quality improvement is useful, the difference is not always clear-cut. First, from a societal perspective, quality assurance aims at stamping out poor-quality care and thus contributes to improving average quality of care. Secondly, proponents of several of the strategies that are included under quality assurance in Table 3.1, such as external assessment (see also Chapter 8) or public reporting (see also Chapter 13), in fact claim that these strategies do contribute to improving quality of care and assuring public trust in healthcare services. In fact, as pointed out in the relevant chapters, the rationale of external assessment and public reporting is that these strategies will lead to changes within organizations that will ultimately contribute to improving quality of care. Clearly, there also need to be incentives and/or motivations for change, i.e. while internal quality improvement processes often rely on professionalism, external accountability mechanisms seek to motivate through external incentives and disincentives – but this is beyond the scope of this chapter. Quality Performance Measure in Health Sciences and Medicine Essay.

3.4. Types of quality indicators

There are many options for classifying different types of quality indicators (Mainz, 2003). One option is to distinguish between rate-based indicators and simple count-based indicators, usually used for rare “sentinel” events. Rate-based indicators are the more common form of indicators. They are expressed as proportions or rates with clearly defined numerators and denominators, for example, the proportion of hip fracture patients who receive antibiotic prophylaxis before surgery. Count-based indicators are often used for operationalizing the safety dimension of quality and they identify individual events that are intrinsically undesirable. Examples include “never events”, such as a foreign body left in during surgery or surgery on the wrong side of the body. If the measurement purpose is quality improvement, each individual event would trigger further analysis and investigation to avoid similar problems in the future.

Another option is to distinguish between generic and disease-specific indicators. Generic indicators measure aspects of care that are relevant to all patients. One example of a generic indicator is the proportion of patients who waited more than six hours in the emergency department. Disease-specific indicators are relevant only for patients with a particular diagnosis, such as the proportion of patients with lung cancer who are alive 30 days after surgery.

Yet other options relate to the different lenses of the framework presented in Chapter 2. Indicators can be classified depending on the dimension of quality that they assess, i.e. effectiveness, patient safety and/or patient-centredness (the first lens); and with regard to the assessed function of healthcare, i.e. prevention, acute, chronic and/or palliative care (the second lens). Furthermore, it is possible to distinguish between patient-based indicators and event-based indicators.  Quality Performance Measure in Health Sciences and Medicine Essay.Patient-based indicators are indicators that are developed based on data that are linked across settings, allowing the identification of the pathway of care provided to individual patients. Event-based indicators are related to a specific event, for example, a hospital admission.

However, the most frequently used framework for distinguishing between different types of quality indicators is Donabedian’s classification of structure, process and outcome indicators (Donabedian, 1980). Donabedian’s triad builds the fourth lens of the framework presented in Chapter 2. The idea is that the structures where health care is provided have an effect on the processes of care, which in turn will influence patient health outcomes. Table 3.2 provides some examples of structure, process and outcome indicators related to the different dimensions of quality.

Table 3.2

Examples of structure, process and outcome quality indicators for different dimensions of quality.

In general, structural quality indicators are used to assess the setting of care, such as the adequacy of facilities and equipment, staffing ratios, qualifications of medical staff and administrative structures. Structural indicators related to effectiveness include the availability of staff with an appropriate skill mix, while the availability of safe medicines and the volume of surgeries performed are considered to be more related to patient safety. Structural indicators for patient-centredness can include the organizational implementation of a patients’ rights charter or the availability of patient information.Quality Performance Measure in Health Sciences and Medicine Essay.  Although institutional structures are certainly important for providing high-quality care, it is often difficult to establish a clear link between structures and clinical processes or outcomes, which reduces, to a certain extent, the relevance of structural measures.

Process indicators are used to assess whether actions indicating high-quality care are undertaken during service provision. Ideally, process indicators are built on reliable scientific evidence that compliance with these indicators is related to better outcomes of care. Sometimes process indicators are developed on the basis of clinical guidelines (see also Chapter 9) or some other golden standard. For example, a process indicator of effective care for AMI patients may assess if patients are given aspirin on arrival. A process indicator of safety in surgery may assess if a safety checklist is used during surgery, and process indicators for patient-centredness may analyse patient-reported experience measures (PREMs). Process measures account for the majority of most quality measurement frameworks (Cheng et al., 2014; Fujita, Moles & Chen, 2018; NQF, 2019a).

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Finally, outcome indicators provide information about whether healthcare services help people stay alive and healthy. Outcome indicators are usually concrete and highly relevant to patients. For example, outcome indicators of effective ambulatory care include hospitalization rates for preventable conditions. Indicators of effective inpatient care for patients with acute myocardial infarction often include mortality rates within 30 days after admission, preferably calculated as a patient-based indicator (i.e. capturing deaths in any setting outside the hospital) and not as an event-based indicator (i.e. capturing death only within the hospital). Outcome indicators of patient safety may include complications of treatment, such as hospital acquired infections or foreign bodies left in during surgery. Outcome indicators of patient-centredness may assess patient satisfaction or patients’ willingness to recommend the hospital. Outcome indicators are increasingly used in quality measurement programmes, in particular in the USA, because they are of greater interest to patients and payers (Baker & Chassin, 2017). Quality Performance Measure in Health Sciences and Medicine Essay.

3.5. Advantages and disadvantages of different types of indicators

Different types of indicators have their various strengths and weaknesses:

• Generic indicators have the advantage that they assess aspects of healthcare quality that are relevant to all patients. Therefore, generic indicators are potentially meaningful for a greater audience of patients, payers and policy-makers.
• Disease-specific indicators are better able to capture different aspects of healthcare quality that are relevant for improving patient care. In fact, most aspects of healthcare quality are disease-specific because effectiveness, safety and patient-centredness mean different things for different groups of diseases. For example, prescribing aspirin at discharge is an indicator of providing effective care for patients after acute myocardial infarction. However, if older patients are prescribed aspirin for extended periods of time without receiving gastro-protective medicines, this is an indicator of safety problems in primary care (NHS BSA, 2019).

Likewise, structure, process and outcome indicators each have their comparative strengths and weaknesses. These are summarized in Table 3.3. The strength of structural measures is that they are easily available, reportable and verifiable because structures are stable and easy to observe.  Quality Performance Measure in Health Sciences and Medicine Essay.However, the main weakness is that the link between structures and clinical processes or outcomes is often indirect and dependent on the actions of healthcare providers.

Table 3.3

Strengths and weaknesses of different types of indicators.

Process indicators are also measured relatively easily, and interpretation is often straightforward because there is often no need for risk-adjustment. In addition, poor performance on process indicators can be directly attributed to the actions of providers, thus giving clear indication for improvement, for example, by better adherence to clinical guidelines (Rubin, Pronovost & Diette, 2001). However, healthcare is complex and process indicators usually focus only on very specific procedures for a specific group of patients. Therefore, hundreds of indicators are needed to enable a comprehensive analysis of the quality of care provided by a professional or an institution. Relying only on a small set of process indicators carries the risk of distorting service provision towards a focus on measured areas of care while disregarding other . Quality Performance Measure in Health Sciences and Medicine Essay.