Six domains of quality in medical care were outlined in its 2001 report Crossing the Quality Chasm by the Institute of Medicine. These included safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.
But, Dr. Tara Bishop writes in a new viewpoint article published online March 21, in the Journal of the American Medical Association
), current quality measures for the outpatient setting do not include all of these domains. As a result, quality measurement and quality improvement efforts in the outpatient setting have neglected critical areas of high quality care.
"The majority of outpatient quality measures focus on preventive care, chronic disease care and, to some extent, timeliness of care and patient centeredness," says Dr. Bishop, an assistant professor of public health and assistant professor of medicine at Weill Cornell Medical College. Dr. Bishop 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. "But safety, high-level effectiveness, coordination and efficiency are not captured in the current measures of outpatient quality."
Dr. 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 Dr. Bishop. Accountable care organizations (ACOs), primary care models such as the patient-centered medical home, payment-for-performance and bundled payments all tie payment into measures of quality. Therefore, Dr. 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 Dr. 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. 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."
Dr. Lawrence P. Casalino, the Livingston Farrand Associate Professor of Public Health and chief of the Division of Outcomes and Effectiveness Research at Weill Cornell says, "Dr. Bishop makes important suggestions for adding neglected areas of outpatient quality measurement to the current measures being used. Her strategies, if implemented, could significantly help to improve patient care."
"This article explores the concept of 'high-level quality,' which is not sufficiently addressed in current measures of patient care quality," says Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor and chairman of the Department of Public Health at Weill Cornell. "As Dr. Bishop alludes, the emphasis on higher level quality measures like diagnostic accuracy and eliminating diagnostic errors has the potential to garner more support from practicing physicians since this is a goal that they all strive for."
"And this may be an optimal time to push the outpatient quality envelope," says Dr. Bishop, and she outlines why.
According to Dr. Bishop, 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 medical records can now more easily 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 through organizations such as the Patient-Centered Outcomes Research Institute (PCORI).
"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," says Dr. Bishop.