Welcome to episode two, framework for measures.

Let's take a trip. Let's say you want to travel from San Francisco to Miami? What
measures will you use to assess the quality of your trip? Well, it may be tempting
to jump to the outcome. Did you get to Miami? Did you make it in time? You
allowed yourself to get there and within your budget. In addition to outcomes,
there may be important structure and process measures you would want to
consider to gain a more comprehensive assessment of your trip. Structural
measures might include the type and size of the vehicle you travelled in. Process
measures might include the route you chose, was it an easy drive with interesting
scenery? How many stops did you make? You might also want to assess how
comfortable the seats were in the car, or how interesting your companions were,
or the overall experience of your trip.
Of course, measuring healthcare is a little bit more complicated than measuring a
car trip, but structure, process, outcome remain a useful framework. So let's
take a deeper dive now into each type of measure.
Structure measures relate to the capabilities in assets of an organization
that are presumably related to producing high quality care. An advantage of
structural measures is that they're relatively easy to understand, to measure, and
often to act upon. They also have some face validity. For example, it might be hard
to imagine high quality hospital care being provided in a run down facility with
inadequate equipment and poorly trained staff. Most structural measures are
used in large organizations and had historically been the backbone of
accreditation programs. Some commonly used measures of structure include
 Staff to patient ratio. Is it adequate to meet the needs of patients?
 Staff competency. Do staff have the right training for their jobs?
 Well defined policies. Are policies in place to guide care decisions and
set expectations?
 Adequacy of environment. Do operating rooms and patient rooms have
specific amounts of space and equipment?
 fine levels of details such as the availability of safe needle disposal
devices.
To be a useful healthcare measure, there should be strong empirical
(practical) data linking low levels of performance on a structural measure to
poor outcomes of care.
If for some reason, it's possible to provide high quality outcomes with lower
levels of staff or poorly maintained technology, for example, the measure's not
useful to improving care.
Unfortunately, in many cases, there is an assumed, rather than empirically
proven, link between structure and outcome measures. Which has, in many
instances, diminished (decreased) the perceived value of these measures.
However, it should be noted that where there is either very strong face validity or
a proven link, structural measures can be foundational.
Let's turn to process measures. The US Agency for Health Care Research and
Quality, or AHRQ, defines a process as a healthcare related activity
performed for, on behalf of, or by a patient.
Process measures provide information about whether or not a certain
action has or has not taken place, such as a medication given, a blood
pressure taken, an immunization provided, or a test ordered. As with
structural measures, the utility of a process measure depends on it being
linked to an important outcome.
For example, giving an immunization that was not at all effective in preventing
influenza would not be a useful measure of quality care for influenza.
 We also have to be careful to determine if there are other equally
effective processes that can create the same outcome. For example, a
phone call might be just as effective as a visit for follow up of a change in
medication.
When there are proven links between process measures and outcomes,
process measures may be a very useful adjunct to outcome measures
because they are often easier to gather and are usually directly actionable.
For example, noting and intervening to raise a low rate and using a checklist to
prevent central line infection, is more directly actionable than simply knowing
you have a central line infection rate that's high.
 Measures of process have traditionally been used to look for situations
where underuse of interventions or processes are likely to lead to
poor outcomes. Examples include underuse of screening for colon cancer,
breast or cervical cancer, or diabetes or hypertension, which all lead to
failure of early diagnosis and treatment. In addition to gauging underuse,
 process measures can also be used to determine the potential overuse
of an intervention. For example, if a given facility does screening pap
smears at a rate of one every six months, the frequency can at least raise
questions as to whether the procedure is being over used as compared to
national and safety guidelines.
 Process measures can also show inappropriate use. An example of
inappropriate use is the widespread use of antibiotics to treat a viral upper
respiratory infection.
Okay, let's move into outcome measures. An outcome is simply defined as the
health state of a patient resulting from health care. It is simply what happens
to a patient as a result of some process or treatment.
There are many outcomes that can be measured, including
 mortality,
  morbidity,
 length of stay,
 patient satisfaction,
 and outcomes associated with specific treatments.
There's a great appeal in looking at outcome. We apply a treatment and we simply
look at what happened. We want to know that our patients have gotten to the
health state that is the goal. However, in many respects, outcome is often quite
complex. For example, the outcome of coronary bypass surgery could be defined
as the patient being alive at the end of a procedure, at six weeks, at one year or at
ten years, or free from angina at one year, or some combination of these
outcomes.
There are several major challenges to relying on outcome measures.
 First, there are relatively few situations where intervention is the only
factor determining the outcome. For example, success in treating
hypertension has been shown to be dependent on many factors
including adherence to medication, diet, and other factors not directly
under the control of healthcare providers or the healthcare system. In
addition, age, sex, and severity of illness are all factors that can also affect
outcomes. Statistical methods for taking these factors into account are
referred to as risk adjustment. In order to risk adjust, there needs to be a
large population to apply the measure to. When developing and applying
outcome measures, statisticians are indeed your best friends in
determining methods that lead to valid outcome measures.
 Another challenge in measuring outcomes is that the distance in time
between the treatment, such as control of blood pressure, and any
definitive outcome, such as heart attack, stroke or death, can be decades.
While focusing on what is often termed an intermediate outcome is helpful, there
is a less than perfect correlation between blood pressure control and mortality,
other than at very high levels of blood pressure. Even for procedures like surgery,
there's often a fairly long gap between the treatment and outcome desired that
makes gathering out come measures challenging. For example, it would be
difficult to measure the distance a patient can walk without pain at six months
after knee surgery.
 In addition, most outcome measures are not directly actionable. For
example, a high rate of reoperation after bariatric surgery does not indicate
what problem it actually is causing the high rate of reoperation.
 Another consideration with outcome measures is that patient
attributes, such as weight, can influence outcomes.
  The patient experience of care is another important set of measures
that are usually classified as outcome measures. Namely, measures related
to patient reported outcomes of care including their experiences in
receiving healthcare. These measures gather information directly from
patients and can include everything form their opinions about parking to
appointment access, whether they felt listened to and respected, as well as
physical outcomes such as how far they can walk without pain, or if they
can shop, cook, or use public transportation independently.
The centers for Medicare and Medicaid in the US requires hospitals to report
measures of patient experience of care. These measures are reported through
a public website on hospital quality called Hospital Compare. There are also
surveys that assess patient experience of care for other settings, including
nursing homes, dialysis centers, surgical centers, ambulatory care and
more. The Agency for Healthcare Reasearch and Quality maintains a website with
information about a variety of tools to assess patient experience of care that are in
the public domain and can be downloaded. So additional information is included
with the resources for this model.
To show how structure, process, and outcomes measures could work together, let's
look at an example of an older patient who needs hip replacement surgery. In order
for the surgery to be successful, one might start with structural measures that are
foundational to high quality hip surgery, including having a surgeon credentialed, at
least by the hospital, and an operating room with appropriate equipment that has
been reviewed for safety. Process measures might include the use of appropriate
surgical procedure as well as the correct delivery of anesthesia. Outcome measures
could include no complications during the surgery or hospital stay. That the patient
being able to walk one block without pain after a specified period of time, and the
patient reporting the experience of care as respectful and responsive to their needs.
While these outcome measures alone might suffice to uncover instances per
quality, it would still take measures of process or structure to pinpoint the
problems. Moreover, as an illustration of the importance of structure and process
measures, an unqualified surgeon, or an ill-equipped hospital, would put the
patient and health facility at risk for an avoidable harm.
There are growing numbers of sets of measures that are being used to
measure quality in specific areas.
 One of the early data sets that continues to evolve is the healthcare
effectiveness data and information set, otherwise known as Hedis. Hedis
was developed and is maintained by the National Committee for Quality
Assurance and Hedis is used by more than 90% of America's health plans to
measure performance on important dimensions of care and service. The
 Hedis performance measures are standardized so that health plans
can be compared.
 The agency for health care research and quality supports a website called
The National Quality Measures Clearing House, that has a listing of
measure with their full descriptions.
 The Joint commission has the Oryx measures that are integrated into
their accreditation process for hospitals.
In addition, many professional organizations have developed measures related
to their specific area of practice, such as
 radiology physician performance measurement set and the
 nursing database of nursing quality indicators.
There are also measures related to specific disease management, such as diabetes,
as well as measures related to delivery systems, such as accountable care
organizations and health plans as previously noted. In addition payers, such as
Medicare, require that certain measures be reported as part of payment
requirements. These data sets are specific to settings. Many private payers
require the reporting of individual provider data, and that data may be used to
determine whether the provider will continue to be part of that payer's network.
So in choosing a measure, given the large number of measures that have been
developed and which are now required for reporting in the US and many other
countries, some providers, as you might understand, are feeling overwhelmed
with data collection requirements and with trying to sort out which results are
useful and helpful in guiding quality improvement. While some of this confusion
and burden is due to the relatively early stage of quality measurement
improvement, there's clearly a great need to re-examine what information is
really critical and to begin to streamline reporting requirements, and to
include only those measures that are important and useful and harmonize
the measures where possible. Harmonize means that similar measures, those
with the same measure focus or with the same population focus, or definitions
applicable to many different measures will have the same specifications so that
the same information can be used for all required reporting and will produce
results that are comparable. The National Quality Forum has established
guidelines for harmonization of measures and continues to work in this very
important area. As you can see, there are many different types of measures and
measure sets from many different aspects of care. With so many measures to
choose from, it's important to have criteria for selecting the right measures for a
given setting or situation. In the next episode, we'll examine the attributes of a
useful measure. So, see you soon in the next episode.