Quality measurement for doctors' offices needs improvement, doctor says

March 22, 2013

Quality measurement and quality improvement efforts in the outpatient setting have neglected critical areas of high-quality care, according to one physician.

Quality measurement and quality improvement efforts in the outpatient setting have neglected critical areas of high-quality care, according to one physician.

In its 2001 report titled "Crossing the Quality Chasm," the Institute of Medicine outlined six domains of quality in medical care: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. But Tara Bishop, MD, writing in a new viewpoint article published online March 21 in the Journal of the American Medical Association (JAMA), says that current quality measures for the outpatient setting do not include all of these domains.

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

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 healthcare is paid for and delivered," Bishop says. Accountable care organizations, primary care models such as the Patient-Centered Medical Home, payment-for-performance, and bundled payments all tie payment into measures of quality. Therefore, 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," she adds. "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. In the outpatient setting, ‘never' events include prescribing errors that could lead to dangerous consequences; failure to inform patients of important test results; medical-setting acquired infections; and failure to properly monitor for adverse effects of treatments. Examples of higher-level quality measures include diagnostic accuracy and diagnostic error prevention, treatment decisions for complex conditions or in the face of uncertainty, and judicious use of resources."

Bishop outlined why "this may be an optimal time to push the outpatient quality envelope. She says that the medical community is defining more and more quality measures through comparative effectiveness research and through expert panels when that research is incomplete or inconclusive. Also, electronic health record systems now more easily can capture clinical data that are not captured in claims. In addition, there is interest in new measures and increasing funding for development of these measures. 

"Although it will be challenging, improving quality measurements of outpatient care needs to be a priority for the medical community, and more work must be done to develop, test, and use new measures," Bishop says.

This study was supported by a National Institute on Aging Career Development Award and in part by funds provided to Bishop as a Nanette Laitman Clinical Scholar in Public Health.