tive communication.
· Use of new technologies and innovations that improve patient outcomes and experience
· Participation in CME
Governmental Entities Definitions:
· Monitoring quality of care through personal case review and peer review.
· Commitment to develop and implement appropriate well-defined quality measures in daily practice.
These last two elements shift the narrative from measurement of physicians as a population on the same set of metrics to having each physician consider her / his own practice and patients in order to construct a process of serious self-evaluation.
The Agency for Healthcare Research and Quality( AHRQ) defines health care quality through six domains: Safe, Effective, Patient-Centered, Timely, Efficient and Equitable.
Medicare has reduced the number of its measures from 764 in 2017, to 489 in 2024. The framework CMS uses in its Meaningful Measures 2.0 is established on a house of values: https:// www. cms. gov / medicare / quality / cms-national-quality-strategy / meaningful-measures-20-moving-measure-reduction-modernization
CMS’ stated goals are to“ drive improvement” by creating measures for high value conditions. As with employers, the assumptions are that doctors, hospitals and other health care providers( termed“ measured entities”) will make the adjustments in training and technology to show improved measured results. CMS recognizes that there are costs and burdens to practices, and burdens to patients who are completing satisfaction scores. To reduce burdens to practices, CMS is moving toward digital quality measurement capture. The downside is that electronic medical records are notoriously poor in capturing the physician thought process. In other words, digital quality measurement is limited to data elements in the medical record and not the quality of interaction with the patient, let alone the impacts beyond the doctor-patient interaction, as Dr. Donabedian has described.
Patient Perspectives
In a 1990 CMS analysis of quality, the authors noted that patient focus groups tend to value first the experience of care over the outcomes of care. However, physicians in their interviews defined quality in terms of the evidence-based approach. The Picker Institute in working with patients developed its Person-Centered Care model to enhance the patient experience while promoting evidence-based care. Picker’ s eight principles are fast access to reliable health care advice; positive therapeutic relationship with effective treatment; continuity of care and smooth transitions; involvement / support by family and caregivers; clear information, communication and support for self-care; involvement in decisions and respect for preferences; emotional support, empathy and respect; and finally, attention to physical and environmental needs.
Quality may be in the eye of the beholder, but the measurement of quality is giving physicians an administrative black eye. While employers and the government are looking to the efficiency of standardization of care, that approach ignores all the other variables impacting patient outcomes. Patients and their families are looking for positive experiences with a certain trust that outcomes are roughly similar between physicians and hospitals. Doctors want to practice at the top of their license without excessive administrative burdens. Now may be the time for doctors to take a lead defining health care quality from technical, experiential, resource stewardship and patient outcomes perspectives. At the same time, we must consider novel ways to capture that information so as to reduce the burden on the profession. We would like to invite suggestions, comments and brainstorming to develop pilot quality engagement tools in Louisville.
References:
Donabedian A, The Quality of Care: How can it be assessed, JAMA Sept 23, 2988: 260( 12): 1743-1748
Boone C, Zink A, Wright BJ, Robicsek A, Value-Based contracting in clinical care; JAMA Health Forum. Aug 23, 2024; 5( 8): e242020
AMA Code of Medical Ethics 1.1.6 Quality
Agency for Health care research and Quality; Six domains of health care quality; https:// www. ahrq. gov / talkingquality / measures / six-domains. html( last accessed March 31,2025)
Lohr KN ed; Medicare: A Strategy for quality assurance, volume II: Sources and methods; The National Academies ISBN: 0-309-55992-8; 1990
Sala F, Roadmap: An Employer’ s Perspective on Health Care Quality Improvement. MorganHealth, JP Morgan Chase https:// www. morganhealth. com / health-care-quality-milestones. htm( last accessed March 31, 2025)
Picker, The Picker principles of person centred care. https:// picker. org / who-weare / the-picker-principles-of-person-centred-care /( last accessed March 31, 2025)
Santana MJ, Manalili KM, Zelinsky S, et al; Improving the quality of person-centred health care from the patient perspective: development of person-centrerd quality indicators. BMJ Open 2020; 10: e037323; Oct 12, 2020.
Dr. James is an internist / pediatrician seeing patients at Family Health Center.
Dr. James and Louisville Medicine would like to invite your thoughts and suggestions on measurement of health care quality. With sufficient interest a brainstorming group may be formed with the goal of piloting our own measures, reducing administrative burdens and restoring the joy in practice. Please contact Kathryn Vance at kathryn. vance @ glms. org if you have any feedback.
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