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What Is Healthcare Quality Measurement?

Jane Hyatt Thorpe1 and Jesse M. Pines2,3

1Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA

2US Acute Care Solutions, Canton, OH, USA

3?Department of Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA

What Is Quality Healthcare?

What is quality in healthcare? The answer to this question is complex and varies by stakeholder, their perspective, and their connection to the healthcare system.

For patients, priorities include achieving optimal health outcomes, symptomatic relief, and ease of interacting with the system (e.g., scheduling visits and picking up prescriptions). Communication and coordination with and across clinicians (e.g., primary and specialty care) is also important, as well as having trusted relationships. For clinicians and providers, the priority is to optimize clinical outcomes. Clinicians and providers focus on ensuring care is delivered appropriately according to accepted clinical standards and available resources and that they are receiving reimbursement relative to cost and resources associated with the care provided. For health plans and payers, priorities include ensuring their enrollees achieve good health outcomes efficiently based on time and resources available through their network of clinicians and providers under a profitable business model. For state and federal regulators, priorities include ensuring large patient populations (e.g., Medicaid and Medicare) receive timely, appropriate care efficiently and within available fiscal resources. These are just four examples of the broad spectrum of stakeholders that also includes a range of state and federal healthcare agencies and programs, pharmaceutical and medical device manufacturers and suppliers, ancillary providers, social services organizations, and other healthcare support networks, as well as significant variation within these groupings (e.g., from large health systems to solo physician practices), among others.

Taking these perspectives into consideration, the non-profit, independent National Academy of Medicine (NAM) defines quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge [1]." The Institute of Medicine (IOM), the predecessor group for NAM, defined six key attributes of quality healthcare applicable at the individual and population levels: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity [1].

Over the last 60?years, the healthcare system has grown exponentially with expanded access to care. There have been expanded forms of insurance through the U.S. Medicare program - which primarily serves individuals aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions, as well as state-based Medicaid programs - which provide health coverage to eligible low-income individuals and families, including children, pregnant women, the elderly, and people with disabilities. Private insurance also has expanded, as have new models of care delivery and technological advances to treat and cure disease and extend longevity. This has occurred alongside the continued evolution of health and wellness as well as disease burden and a growing population that is living longer and experiencing more acute healthcare needs. In parallel, the cost of healthcare services and care delivery has increased significantly. Ongoing research consistently shows not only variation in the quality of care delivered but also disparities. There is broad variation in both access to care and quality.

In response to these trends, a quality measurement enterprise has emerged. Details of how this enterprise works are described throughout this book. Importantly, the process of how quality is measured and how quality measures are used continues to evolve. Ultimately, measurement is designed to support improvements in healthcare delivery, lead to action that results in reductions in preventable or avoidable healthcare expenditures, and improvements in equity.

What Is Healthcare Quality Measurement?

More than two decades ago, two seminal IOM reports - To Err Is Human: Building a Safer Health System (2000) [2] and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) [1] - galvanized the foundation of the current quality measurement and improvement enterprise. Together they highlighted the impact of preventable errors in the American healthcare system and sparked a national call to improve the quality and decrease the rate of cost growth. Robust evidence that collectively points to the disconnect between high spending and healthcare quality and to serious deficiencies in quality has continued to fuel these efforts. The broader goal is often commonly referred to as the triple aim: (1) improving the patient experience, (2) enhancing population health, and (3) reducing per capita cost [3]. This strategy has been adopted by the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), and other institutions and organizations in the private sector. More recently, an emphasis on improving the clinician experience (collectively referred to as the quadruple aim) and an emphasis on equity (collectively referred to as the quintuple aim) also have informed these goals along with patient safety and accountability.

Much work has been done to inform how to define and measure the attributes associated with quality healthcare in a meaningful way. These efforts are intended to enable consistent comparisons on metrics and to foster the development and implementation of consistent processes and structures to reduce variation and improve outcomes. This often also involves improvements for the individuals, institutions, and organizations that deliver care. Ideally, quality measurement should drive improvement in care delivery, inform clinicians and providers and consumers, and influence payment and other incentives for quality improvement. These efforts have evolved greatly over time.

Evolution of Healthcare Quality Measurement

Early Efforts

Well before the IOM work in the early 2000s, early quality measurement and improvement efforts date back to the mid-1800s, where an observant physician, Dr. Ignaz Semmelweiss, determined that handwashing prior to birthing reduced the risk of infection and mortality. Interestingly, his views were not well regarded by his peers, perhaps in part due to the caustic way he communicated [4]. Additionally, in that same period, there was a growing recognition that the spread of communicable diseases may be limited by better improving food safety and sanitation and tracking statistics. The spread of disease and the impact of poor hygiene and sanitation were increasingly clear among soldiers in tight quarters and led to efforts to improve living conditions for soldiers by Florence Nightingale and others [5].

Licensure and Accreditation (Early 1900s)

As the practice of medicine grew more organized and physicians began affiliating with hospitals, methods to monitor and regulate the delivery of healthcare also grew more sophisticated. Early licensure efforts led by physicians focused on ensuring hospitals met certain standards. One notable physician well-known for his work tracking his patients' outcomes is Dr. Ernest Codman. Codman helped organize the American College of Surgeons and the Hospital Standardization Program that ultimately became the foundation of the Joint Commission on Accreditation of Healthcare Organizations, which today assesses and accredits healthcare entities [6]. As the federal government's role in the infrastructure of delivering healthcare as well as funding for healthcare grows, so do efforts to ensure care is delivered according to set standards.

Role of Medicare/Medicaid and Federal/State Regulation (1960s/1970s)

The concept of government regulation was well established by the time the Medicare and Medicaid programs were introduced in 1965. These programs provide significant federal funding for the elderly, disabled, and low-income populations, generated in large part through tax dollars. As the Medicare and Medicaid programs grew, so did efforts to improve quality through various federally organized organizations and committees, including Utilization Review Committees (1965), Experimental Medicare Care Review Organizations (1971), Professional Standards Review Organizations (1972), Peer Review Organizations (1983), and Quality Improvement Organizations (QIO) (2002). QIOs to this day play an active role in supporting quality improvement.

The Medicare program also introduced a parallel program with standard requirements for providers, now commonly referred to as Conditions of Participation, which individual and institutional providers must meet to receive payments from Medicare. The 1970s also saw expanded application of licensure requirements to advanced practice nurses, physician assistants, optometrists, podiatrists, and psychologists. States established mechanisms to also regulate the expansion and development of new healthcare facilities through...