Question

Describe structure, process, and outcome in the assessment of the quality of medical care and can their relationships be trusted to assure the quality of care in the complex, high-tech world of modern medicine?

Answer 1

Quality measures assess care across the full continuum of healthcare delivery, from the level of individual physicians all the way up to the level of health insurance plans. Hundreds of different quality measures are used in health care. These measures generally fall into four broad categories:

1. structure,
2. process and
3. outcome

Let us discuss each of these measures below.

Structure Measures

Structure measures evaluate the infrastructure of healthcare settings, such as hospitals or doctor offices, and whether those healthcare settings can deliver care. These measures include staffing of facilities and the capabilities of these staff, the policy environment in which care is delivered, and the availability of resources within an institution.

For Example: Does an intensive care unit (ICU) have a critical care specialist on staff at all times?

Process Measures

Determines if the services provided to patients are consistent with routine clinical care. These measures are generally linked to procedures or treatments that are known to improve health status or prevent future complications or health conditions.

Processes are useful in that they give providers clear, actionable feedback and a straightforward way to improve their performance.

For Example: Does a doctor ensure that his or her patients receive recommended cancer screenings?Are nurse practitioners routinely examining the feet of diabetes patients to check for wounds? Are physicians prescribing the appropriate drugs to their diabetic patients?

Outcome

Evaluates patient health as a result of the care received. Outcome measures frequently include traditional measures of survival (mortality), the incidence of disease (morbidity), and health-related quality of life issues. And these measures often incorporate patient-reported information on how satisfied patients are with the health care services they’ve received.

Outcome measures can be particularly useful for patients when they are choosing providers or health care services if the measures come with relevant information on cost.

Example: What is the survival rate for patients who experience a heart attack? What was the amputation rate for patients with diabetes? What percentage of cancer patients went into remission? What was the quality of pain relief for patients who’d had knee surgery?

Quality of Care

All quality measures begin with an evidence base. In general, the process of developing a quality measure includes convening a set of stakeholders to evaluate the evidence and define the parameters of a quality measure.

Steps in this process generally include:

• Convening a committee whose members have expertise on the issue to be measured
• Evaluating the evidence base, including primary research and clinical practice guidelines
• Reaching consensus on the best measurement approach, the scientific soundness of the evidence base, the feasibility of measurement, and how data will be collected
• Developing detailed specifications about what will be measured and how
• Vetting the specifications with key interest groups, such as professional societies or consumer groups
• Conducting rigorous testing to ensure that the measure works as it was designed
• Obtaining final approval by the entity charged with developing the measure

Who develops quality measures?

The entities that develop quality measures include:

• Government agencies, such as the Centres for Medicare and Medicaid Services (CMS) and the Agency for Health Care Research and Quality (AHRQ)
• Private non-profits, such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA)
• For-profit companies, such as Health grades and U.S. News and World Report

With the above information, I am sure you have understood that the process of developing meaningful quality measures and putting them into use is ongoing and will be refined over time.