Assessing quality

What gets measured gets improved.

Robin S. Sharma¹

We talk a lot about quality improvement these days, and with good reason. Providing high-quality care is what drives professionals. Developing continuous quality improvement mechanisms is intrinsic to success in clinical settings, which is why one of the objectives of the Patient’s Medical Home is to carry out ongoing evaluation of the effectiveness of its services (objective 9).² But what is quality and how can it be measured?

According to the Institute of Medicine, quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”³ Traditionally, in medicine, much importance is given to the latter part of the definition, and we focus on assessing recognized best professional practices, as defined in clinical practice guidelines. Are we suggesting appropriate screening tests and prescribing the right medication? These questions are important. In the eyes of the public, our patients, and the health care system, we are first and foremost accountable for providing effective care in accordance with the highest standards of practice. Hence the pertinence for us of obtaining information about our clinical practices. We rely heavily on electronic medical records (EMRs) to generate this information, and rightly so.

But are we in danger of overlooking important dimensions of quality by limiting ourselves to indicators based on clinical practice guidelines? Let’s go back to the definition of quality. What is meant by “desired health outcomes”? Certainly reductions in mortality, hospitalization, and complications are all desired health outcomes. But are they the only outcomes of high-quality services? And when we say desired, desired by whom? By professionals, managers, and decision makers? And what about patients—do they have any say in the matter? What would patients and their families say to us if we gave them a voice? Of course they would talk to us about the importance of practising in accordance with professional standards. They trust us to do so and know that we are in the best position to judge. But they would also talk to us about the importance of timely access to services, taking their preferences and priorities into account when treating their health problems, answering their questions so that they can understand their treatments, and coordinating with one another when we work as a team or refer them to consultants.⁴ So many desired outcomes of our interventions are important to them and contribute—we often forget—to enhancing health care safety.⁵

How are we to know whether we are achieving these desired outcomes as we move toward patient-centred services if we do not assess them? “What gets measured gets improved,” said Robin S. Sharma.¹ By limiting quality assessment to what can be assessed by EMRs, we are limiting ourselves to a single dimension of quality. A few years ago, I and some colleagues, who were practising in family medicine units in our teaching network, decided to assess the quality of care given to a sample of our patients being treated for certain chronic illnesses. We used a validated questionnaire to assess patients’ experiences of care, in addition to looking in our medical records to verify the degree of compliance with practice guidelines. The results surprised us: we were very good with respect to indicators taken from the medical records, but less so with respect to our patients’ experience of care.⁶ This finding allowed us to start thinking about how we could improve this dimension of our practices.

There is only one way to find out if our care is centred on patients: we must ask them. Professionals are often cautious about integrating surveys into the quality “tool kit.” These are “subjective” measures, whereas medical record indicators are “objective” measures. However, accessible and validated instruments are available for assessing these dimensions of quality with patients.⁷ Moreover, it might be easier to carry out a survey of one’s patients than to extract data from the EMR. So, why do without?

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