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

Executive SummaryO_ST_ABSIntroductionC_ST_ABSPrimary 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 organizations 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. O_LIObjective 1. Ensure patient has appropriate access to preventive, acute, or chronic health care services when needed. C_LI - Indicators: O_LINew Primary Care Patient Average Wait Time in Days C_LIO_LIEstablished Primary Care Patient Average Wait Time in Days C_LIO_LIAverage 3rd Next Available Appointment in PC Clinics C_LIO_LITotal Inbound PC Secure Messages to Total Outbound PC Secure Messages (Ratio) C_LIO_LIUrgent Care Utilization Rate O_LIObjective 2. Build a trusting, effective, sustained partnership between the health-care team, the patient, and his/her caregiver(s) towards shared goals. C_LI - Indicators: O_LIPatients Satisfaction Rating of Primary Care Provider C_LIO_LITeam 2 Day Post Discharge Contact Ratio C_LIO_LIPatient-Centered Medical Home Stress Discussed O_LIObjective 3. Deliver safe and effective care that comprehensively addresses a given patients particular ecological, biological, and/or psychosocial needs. C_LI C_LI C_LI - Indicators: O_LIAmbulatory Care Sensitive Conditions (ACSC) Hospitalizations Rate Per 1000 Patients C_LIO_LIDiabetes Patients with HbA1c Poor Control C_LIO_LIDiabetes Electronic Composite Measure C_LIO_LIStatin Medication for Patients with Cardiovascular Disease C_LIO_LIControlling High Blood Pressure C_LIO_LIRenal Testing for Nephropathy C_LIO_LIEffective Continuation Phase Treatment for depression C_LIO_LIHospital-wide all cause 30-day Readmission Rate C_LIO_LITeam 2 Day Post Discharge Contact Ratio C_LI SummaryPerformance 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 O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=122 SRC="FIGDIR/small/21262970v1_ufig1.gif" ALT="Figure 1"> View larger version (44K): org.highwire.dtl.DTLVardef@17f3a29org.highwire.dtl.DTLVardef@1c36cfaorg.highwire.dtl.DTLVardef@127b3d7org.highwire.dtl.DTLVardef@19012e7_HPS_FORMAT_FIGEXP M_FIG C_FIG