Doc urges new look at quality measures

'This may be an optimal time to push the outpatient quality envelope.'

Quality measurement and quality improvement efforts in the outpatient setting have neglected critical areas of high quality care, writes Tara Bishop, MD, in a viewpoint article published March 21 in the online version of the Journal of the American Medical Association.

Bishop is an assistant professor of public health and assistant professor of medicine at Weill Cornell Medical College. She is also the Nanette Laitman Clinical Scholar in Public Health/Clinical Evaluation and an assistant attending physician at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

In its 2001 report, "Crossing the Quality Chasm," the Institute of Medicine outlined six domains of quality in medical care: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity, Bishop notes. Yet, current quality measures for the outpatient setting do not include all of these domains.

[See also: Quality measures 'need refinement'.]

"The majority of outpatient quality measures focus on preventive care, chronic disease care and, to some extent, timeliness of care and patient centeredness," Bishop says. "But safety, high-level effectiveness, coordination and efficiency are not captured in the current measures of outpatient quality."

Bishop notes that other health services researchers have pointed out that problems can arise when quality measurement centers on a small aspect of care and neglects others. These problems include the potential for unmeasured quality to be reduced and conclusions about overall quality to be drawn from a small segment of measured quality. For example, clinicians who are evaluated only for providing preventive care and chronic disease management might focus less on equally – if not more – important aspects of care such as diagnostic accuracy and appropriateness of testing.

"There are many changes being discussed and tried out in this country concerning how health care is paid for and delivered," says Bishop.

She points to accountable care organizations, primary care models such as the patient-centered medical home, pay-for-performance and bundled payments as all tying payment into measures of quality.

[See also: Panel weighs decisions for stage 2 quality measures.]

Bishop stresses it is important to revisit the issue of what quality is measured and consider ways to improve and expand quality measurement.

"The medical community needs to focus more attention on patient safety measures and measures of high-level care," adds Bishop. "To begin, outpatient safety measures could be similar to ‘never' events that have been defined for the inpatient setting, such as surgery performed on the wrong site.