Standardized health care performance measures are used by a range of health care stakeholders for a variety of purposes. Measures help clinicians, hospitals and other providers understand whether the care they provide their patients is optimal and appropriate, and if not, where to focus their efforts to improve.
Public and private payers also use measures for feedback and benchmarking purposes, public reporting and incentive-based payment. Moreover, quality measures are an essential part of making the cost and quality of health care more transparent to all, particularly for those who make decisions about the care they or their loved ones need. For each type of quality information that may need to be collected, there is a type of measure suited to its purpose.
Quality measures apply to various aspects of health care. Avedis Donabedian, M.D., a pioneer in the science of measuring health care quality, identified three overarching categories: structure, process, and outcomes. These are still widely used today. In brief and as defined by Agency for Healthcare Research and Quality (AHRQ):
- Structure measures examine the resources and organizational arrangements are in place to deliver care
- Process measures examine appropriate physician and other provider activities are carried out to deliver care
- Outcome measures examine the results of physician and other provider activities
Due to a gap in standardized measures suitable for accountability uses in pediatrics, CHA has developed a measure selection framework focused predominantly on such measures.
Not all measures are suitable for all efforts or programs. For example, a structural measure identifying whether a hospital unit has any active quality improvement program in place may be suitable measure in the hospital's C-suite scorecard. However, such a measure (any QI program) may not be suitable for payment without additional information about the program and its effectiveness. It is critical to understand the limitations of a specific measure, and the intended use of measure results for a specific effort or program.
Principles for programs of accountability
Accountability programs compare hospitals or health care practitioners to either a benchmark or to each other for the purposes of public reporting, consumer selection, pay for performance, or other programs tying quality and cost (e.g., bundled payment, accountable care organizations).
Children’s hospitals have identified best practices for decision- and policy-makers when tying consequences (i.e., accountability) to quality measurement. Any program evaluating a hospital or health system that produces results upon which decisions may be made must be carefully structured.
Key characteristics of a well-structured program
Transparent. Programs of accountability must be fully transparent about the quality measures utilized such that all stakeholders (e.g., consumers, caregivers, employers, providers, etc.) are aware of all measure topics, detailed measure specifications, data sources, and time periods to which the measures will be applied. Further, the possibility that varying levels of performance may be implied within the program must be fully transparent up front.
Fair. Programs of accountability must put in place processes that are fair to the professionals and institutions being evaluated.
Responsible. Programs of accountability, as all programs collecting sensitive health information, must put in place processes that protect the privacy of the patients and their families.
- They should be designed, implemented, and tested incrementally. Hospitals and providers should have an opportunity to review and comment on measure results before they are publicly reported or applied to payment. Moreover, measures should be publicly reported at least one year before being applied to a payment objective. Optimally, pay for reporting should be implemented before pay for performance.
- Absolute performance thresholds (rather than relative rankings) should be used for payment applications. Pay for performance should include a component of payment for improvement as well as achievement of performance goals.
Key principles for accountability measures
While the analysis throughout CHA's measure selection framework for accountability measures will provide greater detail on ideal measure characteristics, some broad overarching principles are especially important to children’s hospitals in programs of accountability. Specifically, children’s hospitals recommend that measures used for accountability purposes are:
- Meaningful for children and their families/caregivers
- Meaningful for providers that care for children — children's hospitals, physicians, clinicians
- Designed to drive quality, efficiency of care, and performance improvement
- Reliable and valid
- Used in programs that meet the objectives of those programs
- Aligned across care settings, when appropriate
- Aligned across data types, sources, and systems, when possible
- Assembled into measure sets that are aligned with other applications to the maximum extent possible
Conceptual model of pediatric quality measurement
Just as there are many types of quality measures, there are many aspects, or domains, of the health care system that may be measured, such as the affordability and coordination of care. Because of the uniqueness of pediatric medicine, there are certain aspects of health care delivery that warrant particular focus when assessing the quality of pediatric care.
For example, high-quality adult care may require effective patient-provider communication, whereas high-quality pediatric care may require additional communication with parents or other adult caregivers.
Children’s hospitals have identified seven priority domains of pediatric health care quality measurement for purposes of accountability. They were selected based on their importance to pediatrics, with five drawn from the National Quality Strategy and two from the Institute of Medicine, including:
- Effective communication and care coordination
- Effective prevention and treatment
- Affordable care
- Healthy communities and community engagement
- Health and well being
- Person and family-centered care
- Patient safety
When these domains are aligned around the child and family receiving health care services, and applied to all types of care and across the spectrum of care, it forms a conceptual model of pediatric quality measurement. This model is instructive in ensuring care is child- and family-centered, and facilitates analysis of program measure sets to ensure all pediatric-specific domains of care are contemplated by a given program measure set.
The advantage of this conceptual framework is it starts with the child and their family/caregivers, and — based on their health needs or the care they seek (“Types of Care”), and the settings in which they receive care (“Sites and Providers”) — we can identify existing and gaps in measures to inform a program of accountability. We further can determine to which domain the measure belongs.