How Should We Measure Quality Healthcare?

Tom G. Bartol, NP


February 06, 2018

Measuring Quality With Patient-Reported Outcomes

There is a strong emphasis today on quality measures in healthcare. One measure, known as "patient-reported outcomes" (PROs), offers a status report of a patient's health, not his or her satisfaction with care.

A recent study[1] used focus groups that included patients, providers, and healthcare administrators to determine the barriers and benefits of PROs. Although many current outcome measures come from electronic health record (EHR) data, this study explored how PROs may be used in addition to more traditional quality measures.

So how did these various stakeholders feel about PROs? Patients reported that survey length and complexity were the most significant barriers to PROs. Providers identified as the biggest barrier the time required to collect and process survey data. Healthcare administrators reported health literacy to be the greatest barrier to PROs.

The greatest benefit of PROs, according to patients, was the ability to track changes in symptoms and problems over time, helping their providers focus on patients' problems. Providers said the greatest benefit was improving quality of care by maximizing the use of time and focusing on what the patient identified. Finally, healthcare administrators liked the opportunity provided by PROs to enhance disease control with improved clinical outcomes and standardization of care.


Many organizations and programs are striving to measure quality healthcare, most with a goal of improving the care that we give to patients. Unfortunately, many of these programs have become more akin to "report cards," evaluating the clinician rather than the tools to measure or achieve high-quality health outcomes. The measures used are often chosen from data that are easy to collect from the EHR database, which usually means process measures rather than clinical outcomes.

With the intent of improving quality of care, patient care has become more like an assembly line—a one-way process, with scripted questions and processes designed to achieve "quality measures." The measures involve little, if any, input from the patient, nor any discussion of potential benefits, risks, and alternatives. In the past several years, the number of measures that clinicians are required to document in the EHR has grown significantly, with no commensurate increase in time to do this, which leaves less time to deal with the patients' identified needs. Any actual improvement in the quality of care is questionable.[2,3]

What suffers is time to build relationships with patients, learn about the unique needs and situation of each patient, and hear about their goals and desires. It's harder to measure this because there is no check box in the EHR. It is part of the "care" in healthcare and has been shown to improve quality of care. Inquiring about family, activity, job, pets, or even the latest book they have been reading helps to build a connection between patient and clinicians and can lead to better health outcomes.[4,5]

The goal of quality measurement must be to learn and to improve care, not simply to grade processes. Ultimately, clinical outcomes along with patients' perceptions of their health and care are more important than any process measure or fulfillment of guidelines. Guidelines and practice recommendations are not mandates; they are guides or starting points from which care can be planned, accounting for the patient's goals, values, preferences, and desires. Healthcare is a dynamic interaction, something we do with patients, not to them. Any tool that measures this care must be adaptable, not standardized, to meet the diverse population of patients we serve.


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