In 1994, the Institute of Medicine’s (IOM’s) Council issued a white paper, America’s Health in Transition: Protecting and Improving Quality (IOM, 1994a). That white paper was the start of a special initiative on quality of health care that included the formation of the IOM’s National Roundtable on Health Care Quality, which has issued this statement. In the preface to the white paper, Kenneth Shine, M.D., president of the IOM stated that,
By its charter, the Institute of Medicine is committed to efforts that will improve health and health care for all Americans. The members of the Institute, like Americans in general, have many individual views on how to accomplish this. But all of its members subscribe to the commitment to achieving the highest quality of health promotion, disease prevention, and health care for individuals and communities in every part of our nation.
During the next few years, as change continues, we cannot lose sight of the urgent need to monitor and improve the quality of health and the effectiveness of health care within our society. . . . Quality can and must be measured, monitored, and improved. Policymakers, whether in the public or the private sector at local, state, or federal levels, must insist that the tools for measuring and improving quality be applied. These approaches require constant modification and reassessment—that is, the continual development of new strategies and the refinement of old ones. Furthermore, credible, objective, and nonpolitical surveillance and reporting of quality in health and health care must be explicitly articulated and vigorously applied as change takes place.
In January 1997, the presidents of the National Academy of Sciences, the National Academy of Engineering and the IOM issued a paper that synthesized, summarized, and highlighted principal conclusions and recommendations from recent studies (NAS, 1997).
This policy paper extends the IOM’s efforts to inform policymakers, provider organizations and clinicians, purchasers, and consumers about the measurement of health care quality—its uses, methods, promise and current challenges. It is based on a conference held at the IOM in September 1996, “Measuring Quality of Care: State of The Art” and the conclusions of the members of the National Roundtable on Health Care Quality.
Viewed most broadly, the purpose of quality measurement is to secure for Americans the most health care value for society’s very large investment. Knowledge about the state of quality is essential if policymakers are to understand the effects of health of services that are provided and how these effects may differ for different patient populations, health conditions, and settings of care. Such knowledge is also needed to understand whether the organization, delivery, and financing of health care is affecting quality of care, and if so how these health services have affected individual and population levels of physical, mental and social functioning. Quality Measurement Tools and Metrics in Nursing. Furthermore, effectively functioning health care markets require that patients, employers, and other consumers have good information for decisionmaking, including knowledge about health plan, organization, and clinician performance and the efficacy, effectiveness, and cost-effectiveness of health services—both for new services and for those that are well established. In particular, measurement of health care quality serves a range of objectives, including the following:
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providing data to inform quality improvement efforts;
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inspecting and certifying that a facility or individual meets previously established standards;
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comparing groups for a variety of purposes, including selective contracting by purchasers and choice of providers and practitioners by individuals;
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informing patients, families, and employees about the health care decisions and choices they face;
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identifying and possibly eliminating substandard performers—those whose performance is so far below an acceptable level that immediate actions are needed;
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highlighting, rewarding, and disseminating best practices;
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monitoring and reporting information about changes in quality over time; and
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addressing the health needs of communities.
The Roundtable emphasizes that although quality measurement has many uses, one of the most important is to provide information that can be used to improve performance. Improving average performance requires excellent measurement of that performance. Measures used by organizations to improve quality as well as those used to compare organizational performance must be detailed, accurate, and timely to be useful. For example, measures for quality improvement must provide a level of clinical detail and site-specificity to allow managers and clinicians to understand what to change. Measures used for organizational comparisons must include careful sampling and accurate risk- and severity-adjustment to ensure fairness when comparing organizations and individuals with one another or to assess change over time. Quality Measurement Tools and Metrics in Nursing.
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Can Quality of Care be Defined?
The IOM stated in 1990 in Medicare: A Strategy for Quality Assurance that “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 21). This definition has been widely accepted and has proven to be a robust and useful reference in the formulation of practical approaches to quality assessment and improvement (Blumenthal, 1996). Several ideas in this definition deserve elaboration.
Terms in the Definition
The term health services refers to a wide array of services that affect health, including those for physical and mental illnesses. Furthermore, the definition applies to many types of health care practitioners (physicians, nurses, and various other health professionals) and to all settings of care (from hospitals and nursing homes to physicians’ offices, community sites, and even private homes).
The definition emphasizes that high quality care increases the likelihood of good outcomes. It is a reminder that quality is not identical to good outcomes. Poor outcomes occur despite the best possible health care because disease often defeats the best efforts of health care professionals. Conversely, patients may do well despite poor quality care because humans are resilient creatures. The term likelihood recognizes that there is always an unknown aspect of health care, but the services provided are expected to provide more benefit than harm, based on the best available information both about the patient and about the effectiveness of a particular kind of treatment for patients with similar health problems.
The inclusion in the definition of both populations and individuals draws attention to the different perspectives that need to be addressed. On the one hand, there is concern with the quality of care that individual organizations, health plans, and clinicians deliver. On the other hand, attention must be paid to the quality of care across the entire system. In particular, one must ask whether all parts of the population have access to needed and appropriate services, whether services meet or exceed their expectations, and whether their health status is improving. That focus embraces all groups, whether or not they have access to care and whether they are defined by cultural heritage, sociodemographic characteristics, geography (e.g., a state or a region), or diagnosis. It recognizes that such individuals will include the most vulnerable, whether the source of vulnerability is economic, the rarity or severity of the health problem, physical frailty, or physical or emotional impairment.
The phrase desired health outcomes highlights the crucial link between the care that is provided and its effects on health. Focusing on outcomes requires clinicians to take their patients’ preferences and values into account as together clinicians and patients make health care decisions. Quality Measurement Tools and Metrics in Nursing. Determining what is good or poor quality of care requires knowledge of the values that individuals place on various health outcomes and how these may differ among individuals.
Current professional knowledge emphasizes that health professionals must stay abreast of the rapidly expanding and changing knowledge base and use such knowledge appropriately. No matter how good the understanding or measures of quality are today, health care professionals must always be prepared to revise them as new knowledge is generated about what works and what does not work effectively in health care to produce good outcomes for patients. Although the knowledge and practices of individual clinicians are important for high quality care, no health practitioner can stay abreast of this growing body of knowledge without the assistance of good systems of care and good information systems to help ensure that relevant and accurate health information is available when needed. Quality of care can be substantially improved by well-designed systems that prevent and minimize errors and the harms that such errors may cause by coordinating care among settings and among various practitioners.
What Is the Relationship Between Quality and Resource Constraints?
The question is sometimes asked: why does this definition of quality not include the acknowledgment of constraints on resources? Given that views of good care include managing care to get good value for money, why not include in the definition a phrase related to ensuring that appropriate services are efficiently provided, identifying and implementing appropriate quality standards, protecting people from spending more on health care than its additional benefits warrant or subjecting them to more risks than the added benefit warrants?
Compelling reasons exist not to include resource constraints within a definition of quality itself. Quality of care should not be defined on a sliding scale in which judgments about quality vary according to what can or cannot be afforded. Rather, the useful concept of the value of health care incorporates both quality and cost in the following simple equation: value = quality/cost. This equation is a measure of the efficiency with which care is provided where quality produces more benefit than harm.Quality Measurement Tools and Metrics in Nursing. Responsible parties (individuals, public and private payers, and societal agents) should be able to distinguish quality problems from those arising from resource availability whether they are imposed by budget and coverage constraints or by inefficient delivery of care, or both. If quality of care is deficient as measured by established criteria, we should be able to recognize it and then determine why. Reasons might include not only failures of systems of care, lack of knowledge or skills, but also factors related to patients such as lack of access, insurance, or failure to adhere to therapeutic advice.
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Where do Quality-of-Care Concerns Lie?
A comprehensive approach to measuring the quality of care requires attention to three different kinds of quality problems: too much care (overuse), too little care (underuse), and misuse (flaws and errors in technical and interpersonal aspects of care).
Too Much Care: Unnecessary or Inappropriate Care
Examples of overuse include the excessive or unnecessary use of X-ray and other diagnostic tests, unnecessary surgical procedures, and overprescribing antibiotics and some mood-altering drugs (sec Advisory Commission, 1998; Chassin, et al., 1998; Schuster et al., 1998). Those practices may result in still further testing and procedures in a cascade of interventions that might have been avoided and that might make patients vulnerable to harmful side effects. They also waste money and resources that could be put to more effective use.
Too Little Care: Underuse of Needed, Effective, and Appropriate Care
Many studies have demonstrated the large gap between what is known to be effective care and what patients actually receive, regardless of their ability to pay (see Advisory Commission, 1998; Chassin, et al., 1998; Schuster et al., 1998). For example, screening and preventive services such as mammography and immunizations are not as widely provided as most experts believe is appropriate, and many treatable conditions, including serious depression, are often not diagnosed. Even those individuals with insurance often face geographic, cultural, organizational, or other barriers that limit their abilities to seek or receive care. Others do not receive proper preventive, diagnostic, or therapeutic services if they lack health insurance, do not adhere to recommended therapy, or if they delay seeking care.
Most quality-of-care issues today are brought to light in the context of personal health care services for individuals, but many critical problems relate to the population as a whole. The country must be able to know how changes in the organization, financing, and delivery of care differentially affect certain groups of people, especially vulnerable or disadvantaged people who are most at risk of poor care or inadequate access to care. These tasks call for applying quality measures to all types of providers in both the private and the public sectors and to the extent feasible under all financing mechanisms.Quality Measurement Tools and Metrics in Nursing. To measure underuse, however, requires denominator information—that is, identification of the group for whom services would be appropriate. Although denominators can be readily identified for assessing many kinds of underuse problems, establishing a denominator in a general population may not be possible, in particular, when no eligible population is defined. Organizations with enrolled populations, such as managed care organizations, can assess underuse of appropriate services such as preventive care, because they have a defined denominator population that is eligible to receive these services.
Misuse: Shortcomings in Technical and Interpersonal Aspects of Care
Inferior care results when the performance of health care professionals or support systems is inadequate or if practitioners lack mastery of their clinical-practice fields, do not adequately explain key aspects of care, or cannot communicate well with their patients. Cases in point include preventable drug interactions and surgical mishaps, failure to monitor or follow up abnormal laboratory-test results, neglect of appropriate education and information for patients, lack of adequate coordination of care, and insensitivity to the ethnic and cultural characteristics of patients (sec Advisory Commission, 1998; Chassin, et al., 1998; Schuster et al., 1998). Inferior care may also result from failure to include patients as appropriate in decisionmaking or disregard of patient preferences regarding care options.
The Burden of Poor Quality
The literature over the last two decades has documented quality problems throughout the health care system—whether from overuse, underuse, or misuse (Schuster et al., 1998; Advisory Commission, 1998). Millions of Americans do not receive proven effective interventions that save lives and prevent disability. Perhaps an equal number suffer needlessly because they are exposed to the harms of unneeded health care services. Large numbers are injured because of preventable harm from medical treatment. These problems exist in managed care and fee-for-service systems, in large and small communities, and in all parts of the country. Quality Measurement Tools and Metrics in Nursing.
Overwhelmingly, individuals are not to blame for these problems (Berwick, 1990; Leape, 1997). These problems tend to result in part from the immense amount of new knowledge about what works to improve health and what does not (Chassin, et al., 1998). Physicians do not have ready access to all the data that would be useful to them as they care for patients. In large part, quality problems result because health practitioners do not have delivery systems that assist in providing error-free care and in bringing to them timely and relevant information about the patients they care for. It should be emphasized that the object of quality measurement should not be to fix blame on organizations or individuals but to find opportunities to improve health and prevent harm.
Given this overview of the definition of quality and the kinds of quality problems that measurement is intended to measure, the remainder of this statement describes major approaches to quality measurement and the challenges.
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What are the Major Approaches to Quality Measurement?
In a classic formulation of the dimensions of quality of care almost 40 years ago, Avedis Donabedian (1966;1980) described quality as including: structure (viewed as the capacity to provide high quality care), process (now often termed performance), and outcomes.
In general, either processes or outcomes may be valid measures of quality. For an outcome to be a valid measure of quality, it must be closely related to processes of care that can be manipulated to affect the outcome. Likewise, for a process to be a valid measure of quality, it must be closely related to an outcome that people care about. The parts that each of these plays in quality measurement are described briefly below.
Structural Measures of Quality
Structural measures of quality typically include the characteristics of the resources in the health care system, including individual practitioners, groups of practitioners, organizations and systems of care, geographic location, and accessibility of services. They are measures of the presumed capacity of the practitioner or provider to deliver quality health care. For health care professionals, this may include licensure, specialty board certification, and type of training. For facilities, they include government certification and private accreditation, physical attributes including safety, and policies and procedures. Quality Measurement Tools and Metrics in Nursing.
One example of the use of structural measurement is in assessing nursing home care. Much of the discussion of nursing home quality and regulation for remedying known problems concerns the role of structure in determining quality—the facilities, staffing, and training of those who care for nursing home residents. Many residents of nursing homes have serious disabilities and problems that require skilled nursing care. The nursing home workforce, its training and its availability for patient care require careful review to determine whether quality of care is adequate.
Process Measures of Quality
Nowadays, the quality-of-care literature is full of discussions about performance measurement, which is the current terminology related to measuring the process of care. In terms of clinical quality, such measurement often focuses on the diagnosis and management of disease and may also address preventive care such as screening for disease. The results of such measurement are being given to employees, for example, to help them choose health plans. They are sometimes used to create consumer “report cards” that present the results of a variety of quality measures in a standardized format that allows comparisons among plans.
Measures of performance may include interpersonal aspects of care, service, timeliness, and convenience. They may include such topics as providing patients with information and answering their questions and encouraging patients to share in decisionmaking if at all possible.
Technical aspects of care include the timeliness and accuracy of diagnosis, the appropriateness of therapy, complications, and mishaps during treatment, and coordination of care across delivery settings, episodes of care, and professional disciplines. Errors in carrying out the complex series of steps often involved in patient care may contribute to preventable deaths or failure to help patients return to health. Misuse of medications (e.g., the wrong medication choice or dose) are serious and frequent problems found in many organizations and practices.
In nursing homes, frequently cited problems include inadequate care plans, unsanitary and hazardous environments, and unsanitary food. Other issues revolve around performance such as a failure to maintain the dignity of and respect for the residents and the unnecessary use of restraints.
Large gaps exist between what is known to be efficacious in research settings and how such knowledge is used (if used at all) in usual settings of clinical care (Brook and Lohr, 1985). These failures to provide appropriate care (underuse and overuse) or to provide care without error or failure in the systems of care (misuse) can result in considerable harm to patients, including death. For this reason measures of performance are critical measures of quality.
It is important that process measures take into account patient preferences. That is, a given test or procedure may be indicated but not performed because of a patient’s decision, and this does not indicate poor quality.
Outcomes Measurement
Health outcomes include the traditional measures of survival (now commonly expressed as risk-adjusted mortality), unintended effects of treatment (e.g., infection), and the relief of symptoms. Quality Measurement Tools and Metrics in Nursing. Such measures may be specific to a given health problem and may focus on biomedical outcomes (e.g., five-year survival, complications from disease, or successful repair and rehabilitation after a knee injury) or more comprehensive assessments of the effect of an intervention.
Outcomes measures also included patient reports about their health (e.g., a scale that asks an individual if his or her health is “excellent, very good, good, fair, or poor”), or they may include detailed measures of function. Functional outcomes measures may center on limitations in performing daily activities such as going to work, attending school, doing housework, as well as physical, social, and mental functioning.
Patient satisfaction measures address various aspects of patient experience in comparison to their expectations. Well-developed instruments for measuring the effects of changes in systems of care are in use in a variety of care settings and are increasingly sophisticated.
Outcomes measurement is in some ways the ultimate form of quality measurement because what interests most people is whether care has improved the patient’s health. Nevertheless, the pitfalls are great. They include the rarity of some adverse outcomes, the long time periods required for many outcomes to develop, and the difficulty in identifying the components of health outcomes that are attributable to action taken by the health care system. That is, the effect of health care services may be quite small in comparison to the effects of the social and physical environment, or a patient’s genetic makeup or behaviors that affect a patient’s health. Furthermore, to be useful for quality improvement, outcomes data need to provide information with a high level of clinical detail and be provided in a sufficiently clear manner that providers and managers can know what processes must be changed. Some experts in quality improvement urge that understanding the rate at which organizations are improving their care are better than using static measures to identify superior and poor performance at a single point in time.
Donald Berwick distinguishes between the now dominant use of “measurement for judgment” compared to “measurement for improvement” (Berwick, 1996). In the former category he includes report cards, benchmark comparisons, the accreditation process, and employer-based performance surveys. Two issues are particularly salient: first, minimizing unintentional unfair comparisons because of the lack of standardized definitions and inadequate risk adjustment and, second, minimizing the intentional gaming of quality measurement. Berwick and others have pointed out that when quality is measured and results are used to judge individuals and organizations (with the accompanying professional and financial implications of such public reporting), the measurement results quickly become subject to denial (in which the measures and data are attacked as deficient or wrong) and to manipulating the results of measurement, that is altering decisions about which patients or members should be included and excluded in measurement or even which patients should be enrolled or treated. In part, this gaming can be addressed by careful specification of measures and by having external parties audit the data. However, he points out that the use of measurement for judgment detracts from a primary reason for measurement which is to help improve care, so that disease and its effects on health can be addressed. A crucial and ongoing challenge in this area is finding ways to achieve measurement for public reporting that do not undermine measurement for quality improvement. Quality Measurement Tools and Metrics in Nursing.
The Importance of Linking Structure, Process, Outcomes, and Cost
Some observers question the relationship of structural measures or standards to either process or outcome measures because of little empirical evidence of direct connections. Structural standards may provide a baseline in terms of capacity but compliance does not assure that high quality care is being provided. Nor does their use clearly mean that high quality care cannot be provided unless these standards are met. However, continuing attention has been given to the importance of governance, financial structures, the health care workforce, and the capacity to provide accessible and coordinated care. Such standards have been combined with measures of performance and outcome to assess the quality of care (Donabedian, 1980, 1982, 1985; Koran, 1975a, 1975b).
Measures of the quality of care based on processes are well-developed in comparison to outcomes measures. Nevertheless, they are good measures only if those processes can be linked to outcomes that are important to patients. Similarly, outcomes are good measures of quality of care only to the extent that they can be linked to actions on the part of the health care system that can be changed. The actions that health care managers should take if they are aware of poor health outcomes are not always clear. Indeed, the accountability of individual practitioners and of health care systems for patient and population health outcomes is an issue that can often only partially be addressed by health care professionals as they may more accurately be understood as societal issues.
Measurement as a Continuous Process that Serves Multiple Purposes
During the last decade, many in the health care system have begun to apply a model of quality improvement called continuous quality improvement or total quality management. One assumption of this model is that the health care organizations and systems within which professionals practice can always improve. One way to foster this improvement is to set up continuous monitoring systems that alert the organization when performance in some area is slipping or to confirm that efforts at improving care are succeeding, or both. For organizations that have embraced methods of continuous quality improvement, measurement of performance and outcomes is integral to their operations. In such cases the cost of measurement is part of the cost of doing business. Ideally, the collection of information is continuous and detailed, and external reporting of performance uses some of this information.
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Advances in Quality Measurement
For more than 40 years, experts have been working to create reliable and valid ways of assessing the quality of health care for a wide range of diagnostic and therapeutic services and for a broad array of health and medical problems (Donaldson and Lohr, 1990). For some purposes, well-understood measurement tools can be put to immediate, widespread use; for others, the science of quality measurement is in an early stage of development. Many advances and refinements in the field of quality measurement have been made. As the acceptance of these quality measures has increased, so has the audience for them. With this has come the need to create a wider domain of measures that indicate the processes and outcomes of care, and address the concerns of consumers. Also needed are measures that have proven validity and reliability.
Examples of different kinds of measures and methods and their use in quality improvement programs were presented at a September 1996 IOM conference entitled Measuring the Quality of Health Care—State of the Art.* Their inclusion here does not mean to imply these are the only or necessarily the best measures. Rather, they are intended to convey the scope of measures. The examples include:
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Automated ways of reminding physicians and other practitioners about the appropriate use of antibiotics and the creation of a database about infectious agents and their treatments.
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The measurement of risk-adjusted mortality and investigation of the science and art of adjusting the measured outcomes of care to take into account the severity of a patient’s illness and other risk factors such as the presence of other health conditions.
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Measuring errors that occur in organizations, especially in the administration of medications, so that organizations can pinpoint how such errors occur and how to prevent them.
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The development of patient-reported measures of quality that allow organizations to compare a patient’s experience with the patient’s expectations. Quality Measurement Tools and Metrics in Nursing.
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Quality measurement in integrated delivery systems that include multiple settings of care. Such measurements seek to assess the performance of whole systems as well as the performance of parts of those systems for defined episodes of care so that quality improvement efforts within the system can be efficiently targeted.
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The translation of well-developed clinical practice guidelines (e.g., those for screening and prevention as well as those for condition-specific treatments) into performance measures for use by purchasers and patients.
These examples are described in more detail below.
Applying Research Methods to Address Real-World Quality Problems
Some quality measures began as research projects and have then been further developed for routine use. One example is the New York State Cardiac Surgery Reporting system instituted in the late 1980s, when large differences among hospitals in mortality rates following bypass surgery were being reported. The state health department compared the expected hospital mortality rates with the observed rates (Hannan et al., 1994). When large differences were found, the state health department helped the hospitals focus on developing useful interventions.
Measuring the underuse of effective services is a notoriously difficult approach to measuring quality. Yet, models adapting research methods have been shown to be useful in assessing underuse of certain procedures such as cardiac artery bypass surgery and angioplasty among women, Hispanics, and uninsured individuals in New York City. Quality Measurement Tools and Metrics in Nursing.
