Measuring quality of care
Measuring quality of care: considering measurement frameworks and needs assessment to guide quality indicator development

https://doi.org/10.1016/j.jclinepi.2013.05.018Get rights and content

Abstract

Objective

In this article, we describe one approach for evaluating the value of developing quality indicators (QIs).

Study Design and Setting

We focus on describing how to develop a conceptual measurement framework and how to evaluate the need to develop QIs. A recent process to develop QIs for injury care is used for illustration.

Results

Key steps to perform before developing QIs include creating a conceptual measurement framework, determining stakeholder perspectives, and performing a QI needs assessment. QI development is likely to be most beneficial for medical problems for which quality measures have not been previously developed or are inadequate and that have a large burden of illness to justify quality measurement and improvement efforts, are characterized by variable or substandard care such that opportunities for improvement exist, and have evidence that improving quality of care will improve patient health.

Conclusion

By developing a conceptual measurement framework and performing a QI needs assessment, developers and users of QIs can target their efforts.

Introduction

What is new?

  • Quality indicators are qualitative and quantitative measures used in determining the quality of health care

  • Developing a concise and clear conceptual framework can be valuable in guiding development of quality indicators

  • A needs assessment should be performed prior to developing quality indicators with development prioritized for problems with the following:

    • large burden of illness to justify quality measurement & improvement efforts

    • evidence that the quality of care is either variable or substandard such that opportunities for improvement exist

    • evidence that improving quality of care will improve patient health

    • quality measures have not been previously developed or are inadequate

We all want cost-effective health care that delivers the right care, at the right time and place to the right persons [1]. However, evaluations of the quality of medical care conclude that it often falls short of established standards [2], [3], [4], [5]. All these reports acknowledge that information is essential for identifying the nature and magnitude of the problem, implementing corrective actions, and tracking improvement [1]. Care has little chance of improving until it is effectively measured [6]. However, in many domains of medicine, this is not currently being done in a systematic and evidence-based fashion [1]. To further complicate matters, for many health care problems, we have too little evidence to justify what is optimal care for our patients. Quality indicators (QIs) are one tool used to measure quality of care. Multiple approaches to QI development have been described, and at present, there is no consensus on the best methodological approach [7], [8], [9]. To help guide quality improvement efforts, we will describe one approach to develop and evaluate QIs in a two-part article series and use the specific example of quality of injury care to illustrate some of the choices faced by developers of quality measures. In the present article, we will address the following questions:

  • What are QIs?

  • How can we develop a conceptual measurement framework?

  • How can we evaluate the need to develop QIs?

    • Burden of illness—is this an important problem?

    • Opportunity for improvement—what is the current quality of care?

    • Better care, better health—will improving quality of care improve patient health?

    • Gaps in existing QIs

      • What are the existing indicators?

      • What is the supporting evidence base for the indicators?

      • What indicators are currently used in practice, and what opportunities exist to improve them?

Section snippets

What are QIs?

Health care QIs are one type of performance measure borrowed from the industrial process control systems literature [10]. QIs generally consist of a descriptive statement, a list of data elements that are necessary to construct and report the measure, detailed specifications that direct how the data elements are to be collected, the population on whom the measure is constructed, the timing of data collection and reporting, the analytic models used to construct the measure, and the format in

How can we develop a conceptual measurement framework?

Developing a concise and clear conceptual framework can be valuable in guiding development of QIs. A framework can be used to articulate the important domains of measurement and specify elements needing assessment and the pathways by which interventions can be expected to cause the desired outcomes. Conceptual frameworks can incorporate theories and empirical evidence to generate hypotheses or provide explanations for causal linkage.

Multiple quality-of-care frameworks exist [16]. Two of the

How can we evaluate the need for QIs?

In evaluating the need for QIs, it is essential to determine stakeholder perspectives [18]. Information about quality of care has several possible constituents and many potential uses; stakeholders may include patients/public, health care providers, managers, and policymakers. Different stakeholders may have different views and different information needs [19]. For example, organizations caring for patients need aggregate information regarding the quality of care provided and the outcomes

Conclusion

Quality of care cannot be improved until it is measured, and this cannot be accomplished until evidence-informed QIs are available. In many health care domains, increasing numbers of QIs are being developed in efforts to drive quality improvement. But more QIs does not necessarily equate with better quality measurement. Although many opportunities exist to develop QIs, a needs assessment should be performed in advance. Indicator development is likely to be most beneficial for medical problems

Acknowledgments

Dr Stelfox is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates. Dr Straus is supported by a Tier 1 Canada Research Chair in Knowledge Translation and Quality of Care. Funding sources had no role in the creation of this article, and we are unaware of any conflicts of interest.

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