The organizations that are (and should be) most actively engaged in the development of performance measures are the medical specialty societies. Performance measures should be based on high quality clinical guidelines that are systematically developed and assist practitioners and patients in decision-making about appropriate care. Each medical specialty society has a process in place for reviewing and evaluating clinical evidence and creating guidelines for treating conditions relevant to that specialty society.
Performance Measures and the Practicing Surgeon
Though efforts to measure the outcomes of medical and surgical care have been around since the early 1900s, the emphasis on performance measurement for healthcare providers and facilities has increased dramatically in the last ten years. Providers, professional associations, payers, regulators, accrediting organizations, and consumer groups have begun to make significant changes in the way they approach monitoring and improving the quality of healthcare. Generally, quality improvement strategies follow a combination of three strategies: public reporting of performance information, payments to promote high-quality care (pay-for-performance), and structured quality-improvement processes. Each of these can provide powerful incentives for healthcare providers, facilities, and patients to improve the quality of care. However, each strategy depends on the availability of accurate, reliable, and valid performance measures and such measures are not uniformly available across the spectrum of care.
The value of performance measures
Performance measures create an objective assessment of how well healthcare providers adhere to evidence-based standards of care to achieve desired outcomes. Measures can be used to evaluate the structure, process, and outcomes of care. Structural quality measures include such things as staff certifications, accreditation, and whether a practice or facility has the information technology in place to easily and accurately monitor and report care for patients. Structural measures are often thought of as minimum standards—necessary qualifications, but not sufficient to ensure the quality of care.
Measures that look at process of care provide more direct evidence of quality care, since they document whether key processes and procedures took place during the patient’s care. Immunization rates and administration of prophylactic antibiotics to prevent surgical wound infections are both examples of process measures. Most measures of patient experience of care are also process measures, such as whether a doctor explains tests and treatments in a way the patient can understand.
Because process measures only examine components of care, the ultimate measures of quality are outcomes measures that examine whether the outcomes for a population of patients are better, the same, or worse than expected for other comparable patients. Commonly tracked outcomes measures include surgical site infection rates, mortality rates, and rates of hospital readmission within a defined period of time. Outcomes measures better reflect the totality of care provided, not just component processes and procedures.
Measuring surgical quality
To date, most measures of quality in ambulatory care settings have focused on preventive and chronic care. There are some key distinctions in surgical care that affect the way surgical quality is measured. Surgery is more episodic and less focused on chronic disease management, preventive services, and screening. The ultimate outcome produced by a surgical intervention is more immediate and clear than with disease management strategies that may span many years. As a result, surgical care lends itself much more readily to rigorous clinical outcome measurement than primary care. Also, surgeons tend to have more focused areas of practice that make it difficult to apply broad quality-measurement sets. Although there are some measures that may apply across surgical specialties, there also need to be measurement sets that are specific to each surgical specialty.
With such a variety of measures in use throughout the healthcare system, how can a practicing surgeon know if the measures proposed to evaluate surgical performance are useful measures of quality? One way is to find out if the measure has been developed through a rigorous research-based process, such as the process used by the AMA’s Physician Consortium for Performance Improvement (The Consortium).1 The Consortium is composed of representatives of over 50 specialty societies and methodological experts in measure development. They accept proposals for measures from member societies and others, then evaluate and test the proposed measures to ensure they are actionable, are based on established clinical recommendations and evidence, and that necessary data to support the measures are feasible to collect.
Developing a standardized national set of measures
The National Quality Forum (NQF)2 is another organization working to create a standardized national set of measures that can be used to evaluate the entire spectrum of care. The NQF has a broad membership of providers, payers, and health plans. The NQF endorses national standards for measurement and public reporting of healthcare performance data that provide meaningful information about quality of care based on consensus from the broad spectrum of their membership. Thus, the NQF has endorsed quality measures developed by the AMA’s Consortium, which have then been adopted for use by both CMS and private-sector payers and purchasers.
The Academy is a member of the Consortium and is active in a number of efforts to create performance measures for otolaryngology that are evidence-based, represent priority areas for the specialty, and for which data collection is easily accomplished from both paper-based and electronic medical records. We are working with other surgical specialty societies to create performance measures that are common to all surgical specialties. Finally, we are working to aggregate the demand across all of the entities (health plans, purchasers, and the government that are using measures for quality improvement and pay-for-performance to promote agreement on common measurement sets and protect our members from having to report multiple performance measures for different audiences and purposes.
For more information about performance measures and the Academy’s initiatives in this area, please contact the Academy by email at firstname.lastname@example.org.
Physician Consortium on Performance Improvement
Most medical specialty societies choose to work through the AMA's convened Physician Consortium for Performance Improvement (PCPI, also called The Consortium) to develop physician level performance measures.
The Consortium is composed of representatives of over 75 specialty societies and methodological experts in measure development. The Consortium:
Workshops held in cities nationwide will help otolaryngologists, their staff, and other healthcare professionals code correctly, learn risk reduction strategies, and organize business systems.