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In this chapter we will discuss measuring quality of care—general principles of measurement, measures for judging quality, and measures used for the local management and improvement of care—with a focus on measures of particular interest to Hospital Medicine physicians.

Measurement for Performance Assessment

The era of accountability has arrived in medicine. Consumers, purchasers, and providers of health care are increasingly interested in health care quality and safety. Health care value, in which value is a function of quality ÷ cost, is being closely scrutinized as the increasing cost of health care has outpaced inflation over several decades without a demonstrated concomitant increase in quality and safety.

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Practice Point
  • Without measurement, it is impossible to know if something is good or bad, the same or different. It is also impossible to know if efforts to improve care have been successful without measuring the impact of a change. The default position should always be to measure.

Consumers want a high-value product. Selection pressures allow consumers of health care to choose between providers. Historically, the primary decision maker in assessing quality has been the individual patient, with no access to data and little understanding of how to assess quality of care. Reputation and word of mouth have been used to assess quality, and patients tend to follow the advice of their doctors when being referred for additional medical care. As health care costs increase, purchasers of health care on a larger scale look for more objective ways to assess quality. Research reflected in the Dartmouth Atlas of Health Care has demonstrated tremendous geographic variation in costs and outcomes within the United States. Paradoxically, higher expenditures on health care in the United States have not been associated with improved outcomes.

These factors provide the foundation for the push from large-scale purchasers of health care to demand that providers be able to objectively demonstrate the quality of care they provide. The Leapfrog Group, a consortium of health insurance purchasers, encourages hospitals to voluntarily report a variety of measures and makes the resulting quality ratings available to the public ( The Centers for Medicare & Medicaid Services (CMS) and increasing numbers of commercial insurance companies provide incentives for hospitals and physicians to measure and report their health care quality. These purchasers apply selection pressures to improve quality by considering quality performance when choosing network providers or by paying differential rates for performance or participation in quality assessment. Beyond incentives, the mere fact of public reporting has influenced health care providers to turn attention and resources to improvement of quality and safety. Performance measures are markers of care used for public reporting or for incentive payment.

Organizations comparing performance commonly use one of two methods. The first is to compare one hospital's performance against that of peer organizations. This is the method used in ...

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