Essential Indicators of Quality in Primary Care Settings: An Evidence-Based, Structured, Expert Approach

Abstract

Executive SummaryIntroductionPrimary health care has a central role in the workings of the health care system and health of the American public. Thus, a high-performing, high-quality primary care system is essential. As a result, measurement frameworks are needed to assess the quality of the infrastructure, workforce configurations, and processes available in primary care practices due to the complexity of primary care. As part of a larger project supported by AHRQ (grant no. 1 R01 HS 025982), our research team reports the use of an evidence-based approach to compile a targeted set of existing care measures. These measures are prioritized according to their overall contribution and value to primary care. Within this paper, we describe the process by which the performance measures were selected and present the final set of measures resulting from the process.Defining Primary careThe study centers around general primary care settings, which have been defined as, “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” (1)Using PROMESWe adapted an evidence-based approach for measure development, The Productivity Measurement and Enhancement System, or ProMES, to select (modify, when appropriate) and rank existing primary care measures according to value to the primary care clinic. ProMES is a comprehensive performance measure development approach firmly grounded in motivational theory and performance measurement.(2, 3) Through a facilitated focus-group based process, these measures are defined, weighted, and prioritized to create indicators of both overall effectiveness and specific aspects of daily work. This alignment helps individuals and teams to focus their effort more clearly on the most important aspects of their work (i.e., clinical performance) resulting in greater productivity, reduced stress, and less waste of effort.(2, 3) We utilize the ProMES definition of productivity, which is how effectively an organization uses its resources to achieve its goals.One unique feature of ProMES is the resulting measures include contingency curves, or non-linear functions that explicitly tie performance levels on a given measure to its contribution to the organization’s values; in this way, the application of ProMES yields a more nuanced approach to prioritizing work than simple linear weights, while allowing direct comparison(s) between measure(s).ResultsThe design team identified three fundamental objectives for delivery of high-quality primary care. The design team also selected sixteen performance indicators from the 44 pre-vetted measures that already exist in three different data sources for primary care. One indicator, Team 2 Day Post Discharge Contact Ratio, was selected as an indicator for both Objective 2 and 3. In addition, contingency curves were created for each of the indicators using the contingency functions developed by the design team.Objective 1. Ensure patient has appropriate access to preventive, acute, or chronic health care services when needed.–Indicators:New Primary Care Patient Average Wait Time in DaysEstablished Primary Care Patient Average Wait Time in DaysAverage 3rd Next Available Appointment in PC ClinicsTotal Inbound PC Secure Messages to Total Outbound PC Secure Messages (Ratio)Urgent Care Utilization RateObjective 2. Build a trusting, effective, sustained partnership between the health-care team, the patient, and his/her caregiver(s) towards shared goals.–Indicators:Patient’s Satisfaction Rating of Primary Care ProviderTeam 2 Day Post Discharge Contact RatioPatient-Centered Medical Home Stress DiscussedObjective 3. Deliver safe and effective care that comprehensively addresses a given patient’s particular ecological, biological, and/or psychosocial needs.–Indicators:Ambulatory Care Sensitive Conditions (ACSC) Hospitalizations Rate Per 1000 PatientsDiabetes Patients with HbA1c Poor ControlDiabetes Electronic Composite MeasureStatin Medication for Patients with Cardiovascular DiseaseControlling High Blood PressureRenal Testing for NephropathyEffective Continuation Phase Treatment for depressionHospital-wide all cause 30-day Readmission RateTeam 2 Day Post Discharge Contact RatioSummaryPerformance measures selected as part of our modified-ProMES process assist in the implementation of targeted care quality measures prioritized in accordance to their value in primary care. By deriving high-value metrics, organized by care objective with numerically assigned prioritization, we anticipate the results of this paper will apply to a diverse set of stakeholders, including but not limited to policy-makers, primary care clinicians, and administrators in healthcare organizations. Our design team of nationally recognized SMEs joined together in a national panel that consists of diverse stakeholder groups to collectively identify three primary care team objectives, 16 indicators of primary care quality, and 13 indicators which require modification and further work to address gaps which exist in the primary care performance measurement domain. Measures selected as part of this study aim were constructed independent of clinic size or configuration, so that clinics of many configurations (e.g., public vs. private, large vs. small, rural vs urban, team-based vs. traditional) could benefit from their use.Our measure set provides an actionable catalogue of measures that can serve as a first step toward interoperability of electronic health record systems. Future work toward this goal should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as the best way to operationalize these measures for teams working in complex and shifting situations (e.g., rotating team members).Acronyms and Definitions