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Dr. Bruce A. Chernof, MD Headshot

Quality Care As a Driver for Health System Change

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Quality measurement in health care has always been difficult and expensive. In my 30 years in medicine, the focus has been geared more towards measuring outcomes from an acute care perspective rather than quality from the point of view of the individual. For example, documenting hemoglobin A1C levels or body mass index scores may measure clinical quality, yet these markers reveal little about a person's daily living needs and how decisions about their care are made.

Over the years, quality has been limited to three distinct buckets:

  • Is the environment where care is delivered safe and staffed appropriately?
  • Are the technical aspects of care consistent with data driven guidelines?
  • Are patients satisfied with the service they receive?

The problem is that these measures too often do not reflect the totality of the experience of the person receiving care. While these elements are important and necessary, they do not provide a complete look at quality, particularly for those who have serious chronic illness or functional limitations. Most of today's measures do not create enough value for actual health care users and, as a result, have little impact on improving care and lowering costs. The challenge in front of us is to grow the next generation of quality measures that get at the heart of how people experience care delivery and what their values are in these interactions. New measures need to build upon and complement the important medically oriented measures described above.

This next generation of measures will:

  • Define quality as improving the life of a person, not perceiving them strictly as a patient;
  • Place functional outcomes, or how the person receiving care desires to live their everyday life, on par with clinical outcomes; and
  • Create measurement processes that track outcomes over time since functional needs and personal goals change.

What I am proposing here is a new generation of quality of life measures that are built upon a foundation of meeting the needs, values, and preferences of those receiving care as a priority. This next generation of quality measurements will require not only a different mindset - focusing on quality of life in addition to quality of health - but a different tool box as well. Looking at rigorous qualitative measurement techniques, like recurring in-depth interviews or polling methodologies, will be pivotal to collecting and using these kinds of data to judge quality.

The SCAN Foundation recently commissioned several national experts on how to use the most appropriate qualitative techniques to lay out some of the principles and concepts that underlie developing, testing, and operationalizing quality measures. Everybody wants quality care, and the system as a whole wins when it is done well. The problem is that the research does not yet exist to define broad based parameters for quality. Currently, care ranges from very good to disastrous. We need to narrow this bandwidth. Research shows that individuals and families fear quality of life will take a backseat to quality of care, that their voices will not be heard, their choices ignored, and as a result their dignity is diminished.

Care that is both technically correct and consistent with a person's needs, values, and preferences can unlock the potential for making decisions based upon value to an individual's life, payment that prioritizes performance, and to the often-cited yet rarely seen program that delivers better care at lower costs. To fundamentally engage the American public in the future of the health care delivery system, we need to see value through their eyes as people endeavor to live their lives to the fullest, despite limitations. This can best be achieved by putting quality of life measures on the same level with quality of health measures to truly drive health system change.