the National Quality Forum (NQF), and measurement organizations, such as the National Committee for Quality Assurance (NCQA), are currently working to improve the accuracy, utility, and application of performance metrics.

Instead of focusing on processes, some metrics are drawn directly from patient health outcomes. A motivation for this strategy is the fact that what matters to patients is the outcome of their care—the effect of their care on the length of their life, their quality of life, and their overall functioning and well-being. One of the difficulties of this model is accurately measuring outcomes that are relevant for patients rather than limiting assessments to what can be easily measured and ensuring that care decisions flow from patient needs, goals, and circumstances (see Chapter 7 for a discussion of patients’ perceptions and needs in maintaining their health and shared decision-making frameworks). For instance, while mortality can be quantified simply, it provides only a limited picture of the total value a patient receives from a given intervention.

After identifying the metrics that best quantify health outcomes, the next challenge is attributing the effect of a given treatment or the actions of a given provider to these metrics. Some treatments, such as surgical procedures, often allow for closer linkages between a procedure and its outcomes, while others, notably chronic care management, have longer time lags between the provision of care and its ultimate outcomes. For chronic care, the patient’s health depends on years, or even decades, of medical treatments, with many providers being involved in the care process. In addition, worse health outcomes often are associated with factors outside the traditional health care system, such as diet and smoking (McGinnis and Foege, 1993). Assessing the value of care based on outcomes for patients with chronic conditions will therefore require a hybrid strategy that involves evaluating both care processes and health outcomes so value metrics can accurately assess the care provided.


Measurement itself is only part of the improvement process. Transparency on results supplies data that clinicians can use for improvement initiatives, provides information that patients and consumers can use to select care and providers, and draws attention to high-value health care providers and organizations (IOM, 2006, 2010a). Some of the earliest such efforts include New York State’s initiative to report the mortality and complications associated with coronary artery bypass graft surgery and the Health Care Financing Administration’s (HCFA’s) reporting of hospital mortality (Berwick and Wald, 1990; Hannan et al., 1994). Since these initial efforts, multiple reporting systems have been introduced, from the Healthcare

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