Policy recommendations on quality measurement: my reactions

Bob Berenson, Harlan Krumholz and Peter Pronovost are luminaries in the creation of quality and safety measurements in healthcare. They have come together to propose Seven Policy Recommendations to Improve Quality Measurement, published on the Health Affairs blog. They propose a number of thought-provoking ideas but I find myself disagreeing with more of them than I would have expected.

The seven recommendations are:

  1. Decisively move from measuring processes to outcomes.
  2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.
  3. Measure quality at the level of the organization, not the clinician.
  4. Measure patient experience with care and patient-reported outcomes as ends in themselves.
  5. Use measurement to promote the concept of the rapid-learning healthcare system.
  6. Invest in the "basic science" of measure development.
  7. Task a single entity with defining standards for measuring and reporting quality and cost data, similar to the role the Securities and Exchange Commission (SEC) serves for the reporting of corporate financial data, to improve the validity, comparability and transparency of publicly reported healthcare quality data.

I'm fine with recommendations #2 (I'm a sucker for using anything "strategically"), #5 (rapid learning is good) and #6 (there is definitely a need for "basic science").

I'm a big fan of #4 (patient experience and patient-reported outcomes) because these can be generated today for primary care and specialists, patients can relate to the measures, and the measures can be used to drive change to the system from the outside. So I find it odd and even ironic that this recommendation follows immediately after #3, which is to report at the organizational level, not the clinician level. Yes, there are reasons to report at the level of the organization: It makes it easier to obtain statistical significance, more care is provided by teams these days, and some measures - like how smoothly the office flows - have more to do with the overall system than with the doctor. But do these esteemed health experts choose their own providers based just on the "organization" or do they do what I and everyone I know does, which is to give considerable weight to the individual physician they are going to see?

Number 1 (moving from process to outcomes measures) sounds good. But the real issue is that in healthcare the connection between processes and outcomes is not well understood. In other industries -- like manufacturing -- the linkage between process and outcome is well understood; tools like statistical process control can be applied to control processes that then lead reliably to the desired outcomes of end product quality and reduction of waste.

I confess to not fully understanding #7 (creating an SEC equivalent for quality and cost data) but I'm also having trouble getting excited about a further centralization of authority in the measurement field and adding a new police officer. The description refers to quality efforts struggling "to find measures that are scientifically sound yet feasible to implement with the limited resources available." The real issue is the "limited resources," not the lack of an SEC.

The comments section includes insights from a variety of knowledgeable people including those representing regional health improvement collaboratives (RHICs), many of which -- like the authors -- receive support from the Robert Wood Johnson Foundation.

And that brings me to my final point, which is that the recommendations over-emphasize national solutions and underemphasize the role of the RHICs, several of which are innovative, effective and poised to play leadership roles in the healthcare quality movement in their home communities and beyond.