Published On: Tue, Feb 17th, 2015

Quality measurement and management in health care systems

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Maintaining leadership in health care management is unachievable if the quality of health care cannot be measured. A good health care system allows for effective evaluation in order to know what exactly the quality of care is, and how well it is delivered.

Sadly, in most developing countries, there is no mandatory national healthcare system to track the quality of care delivered to the citizens. Much of what is done is spontaneous delivery of health care within an existing cyclic health structure that has existed for many years without recourse to change.

On the other hand, in developed countries, interest in measuring quality of health care has initiated dramatic transformations of health care systems, accompanied by new organisational structures and reimbursement strategies that could affect quality of care.

Why is the measurement of quality in health care difficult in the developing ones? Apart from a lack of documentation about how major illnesses are treated in most health care systems, there are other factors, which include:

  1. A lack of systematic outcome assessment.
  2. A lack of resource evaluation related to quality for specific diseases.
  3. Persisting variations among providers in care for similar patients.
  4. Paucity of formal monitoring systems by health care providers or regulators.

 Assessing quality care

Understanding quality of care is quintessential to effective leadership in health care management. Quality carecan be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, become consistent with current professional knowledge, and divided into different dimensions according to the aspects of care being assessed. This cannot be achieved without effective management; in fact, management is the commitment required to achieve quality health care objectives. It involves coordinating, leading and motivating people in order to achieve a set objective. It entails the efficient use of all available resources.

Our focus here is the measurement of the quality of health care. How do we know how well we are doing? Are there precise measurement tools for measuring an existing health care system?

There are quantitative measures that can be used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes. These quantitative measures are carried out using indicators.Indicators aremeasures that assess a particular health care process. They provide a quantitative basis for clinicians, organisations and planners aiming to achieve improvement in care, and the processes by which patient care are provided. Indicators are a form of clinical quality measures (CQMs).

 About clinical quality measures

      Clinical quality measures(CQMs) are tools that help measure and track the quality of health care services provided by eligible professionals, eligible hospitals and critical access hospitals (CAHs) within a health care system. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care.

CQMs measure many aspects of patient care, including, health outcomes, clinical processes, patient safety, efficient use of health care resources, care coordination, patient engagements, population and public health, and adherence to clinical guidelines.

The importance of using an effective indicator cannot be overemphasised. Indicators serve crucial purposes. They make it possible to:

  1. Document the quality of care;
  2. Make comparisons (benchmarking) over time between places (e.g. hospitals);
  3. Make judgements and set priorities (e.g. choosing a hospital or surgery, or organising medical care);
  4. Support accountability, regulation, and accreditation;
  5. Support quality improvement; and
  6. Support patient choice of providers

Also,the use of indicators enables professionals and organisations to monitor and evaluate what happens to patients as a consequence of how well professionals and organisational systems function to provide for the needs of patients.

However, indicators are not a direct measure of quality. This is because quality is multidimensional; hence, in order to understand and measure quality, different measures must be employed. Although indicators are not sole determinants of measuring quality, they must be ideal indicators. They are said to be ideal if they are based on standards of care. These ideal indicators can be evidence-based and derived from the academic literature. Where scientific evidence is lacking, it can be determined by an expert panel of health professionals in a consensus process, based on their wealth of experience. Thus, indicators and standards can be described according to the strength of scientific evidence for their ability to predict outcomes

 Characteristics of an ideal indicator

An ideal indicator:

* Is based on agreed definitions, and described exhaustively and exclusively;

* Is highly or optimally specific and sensitive; that is, it detects few false positives and false negatives;

* Is valid and reliable;

* Discriminates appropriately;

* Relates to clearly identifiable events for the user (e.g. if meant for clinical providers, it is relevant to clinical practice);

* Permits useful comparisons; and

* Is evidence-based. Each indicator must be defined in detail, with explicit data specifications in order to be specific and sensitive.

It is important to know that indicators may vary in their validity and reliability. Validity is the degree to which the indicator measures what it is intended to measure. This means the result of a measurement corresponds to the true state of the phenomenon being measured. A valid indicator discriminates between cares, otherwise known to be of good or bad quality, and concurs with other measures that are intended to measure the same dimension of quality.

Reliability, on the other hand, is the extent to which repeated measurements of a stable phenomenon by different data collectors, judges, or instruments, at different times and places, get similar results. Reliability is important when using an indicator to make comparisons among groups or within groups over time. These two qualities must be considered when choosing an indicator.

Types of indicators

There are different classifications of indicators that may be useful when considering which should be used for a given purpose in an organisation. An indicator can be any of the following:

* Rate-based or sentinel;

* Structure/process/outcome-related; and

* Generic or disease-specific.

* Type of care, function, and modality-related

Rate-based and sentinel indicators

A rate-based indicator uses data about events that are expected to occur with some frequency. These can be expressed as proportions or rates (proportions within a given time period), ratios, or mean values for a sample population.

To permit comparisons among providers or trends over time, proportion- or rate-based indicators need both a numerator and a denominator, specifying the population at risk for an event and the period of time over which the event may take place. An example of rate-based indicator is: “clean and contaminated wound infection” where the numerator is the number of patients who develop wound infection from fifth post-operative day after clean surgery and the denominator is the total number of patients undergoing clean surgery within the time period under study who have a post-operative length of stay for five days.

Moreover, a sentinel indicator identifies individual events or phenomena that are intrinsically undesirable, and always triggers further analysis and investigation. Each incident would trigger an investigation. Sentinel events represent the extreme of poor performance and they are generally used for risk management. Example is the number of patients who die during surgery.

2.Indicators related to structure, process and outcomes

There are indicators that can be related to structure, process and outcome of health care. ‘Process’ denotes what is actually done in giving and receiving care; that is, the practitioner’s activities in making a diagnosis, recommending or implementing treatment, or other interaction with the patient.

On the other hand, ‘outcome’ measures attempt to describe the effects of care on the health status of patients and populations. Improvements in the patient’s knowledge and salutary changes in the patient’s behavior may be included under a broad definition of outcome and, so, may represent the degree of the patient’s satisfaction with care.

Further,‘structure’ refers to health system characteristics that affect the system’s ability to meet the health care needs of individual patients or a community. Structural indicators describe the type and amount of resources used by a health system or organiSation to deliver programmes and services, and they relate to the presence or number of staff, clients, money, beds, supplies, and buildings.It is important to note that the assessment of structure is a judgement on whether care is being provided under conditions that are either conducive or inimical to the provision of good care.

* Process indicators: Process indicators assess what the provider did for the patient and how well it was done. Processes are a series of inter-related activities undertaken to achieve objectives. Process indicators measure the activities and tasks in patient episodes of care. An example of process indicator is the proportionof patients treated according to clinical guidelines. Some authors include the patient’s activities in seeking care and carrying it out in their definition of the health care process; others limit this term to the care that health care providers are giving. It may be argued that providers are not accountable for the patient’s activities and these, therefore, do not constitute part of the quality of care, but rather fall into the realm of patients’ characteristics and behaviour that influence patients’ health outcomes.

* Outcome indicators: Outcomes are states of health or events that follow care and that may be affected by health care. An ideal outcome indicator would capture the effect of care processes on the health and wellbeing of patients and populations. Outcomes can be expressed as ‘The Five Ds’: (i) Death – a bad outcome if untimely; (ii) Disease – symptoms, physical signs, and laboratory abnormalities; (iii) Discomfort – symptoms such as pain, nausea, or dyspnea; (iv) Disability – impaired ability connected to usual activities at home, work, or in recreation; and (v) Dissatisfaction – emotional reactions to disease and its care, such as sadness and anger.

It should be noted that intermediate outcome indicators reflect changes in biological status that affect subsequent health outcomes. Some outcomes can only be assessed after years, for example, five-year cancer survival. It is, therefore, important to assess intermediate outcome indicators. They should be evidence-based and reflect the outcome (e.g. HbA1c in diabetes). They can be regarded as short-term outcomes.

Therefore, outcome measures must be adjusted for factors outside the health system, if fair comparisons are to be made. In quality assessment, components that relate to the medical care system should be isolated, which is accomplished by controlling for significant confounding factors that contribute to the outcome.


  1. Generic and disease-specific indicators

Generic indicators measure aspects of care that are relevant to most patients, while disease-specific indicators are diagnosis-specific and measure particular aspects of care related to specific diseases. Both generic and disease-specific indicators can focus on structure, process, or outcome.

Generic indicators may be difficult to interpret, especially when making comparisons among hospitals or providers, because there may be profound differences in patient mix. Examples of generic indicators are proportion of specialists to other doctors, registered patients in the emergency department, unscheduled returns to the operating room and in-patient mortality.

Disease-specific outcome indicators can be used to compare hospitals and plans, when data are risk-adjusted. Confounding factors, such as prognostic factors for specific diseases, are likely to be found in the scientific literature for these diseases, thereby, indicating the need for risk adjustment. Example of this type of indicator is the proportion of cardiologists to other doctors treating patients with heart failure at the department of cardiology.

  1. Indicators related to type of care, function, and modality

There are indicators that can be classified according to type of care, function, and modality. These set of indicators, classified by type of care, may be preventive, acute, or chronic.Also, quality measurement can be done based on health care functions such as screening, diagnosis, treatment and follow-up. This must be done alongside the modalities through which the health care process is done. Modalities in the health care process includehistory, physical examination, laboratory/radiology study, medication, and other interventions.

It is critical to evaluate and re-evaluate healthcare performance among professionals and organisations. These indicators can serve as a plumb line if indeed we seek leadership in health care management.

The table below captures this group of indicators and illustrates how they can be classified in quality of care measurement systems, especially in multiple clinical topics. The table displays examples of indicators classified according to type of care, function and modality

Indicator Type of Care Function Modality
Sickle cell disease: children with a positive sickle cell    Chronic Treatment Medication screen of children suspected of being positive for sickle cell disease should be placed on daily penicillin prophylaxis from at least 6 months of age until at least 5 years of age
Urinary tract infection: children with a diagnosed urinary tract infection should be reassessed at 48hours to determine if there is clinical improvement Acute Follow-up Other contact
Well-child care: the child’s weight should be measured at least four times during the first year of life. This information must either be plotted on a growth curve or be recorded with the age/gender percentile Preventive Screening Physical Examination


As always, our passion at the Pharmanews Centre for Health Care Management Development is to drive effective leadership through qualitative healthcare management. It is crucial to know that the measurement of health care quality is greatly aided by the use of relevant quantitative indicators, supplementing other approaches that may include qualitative analyses of specific events or processes. For a healthier Nigeria, indicators can also be important with regard to prevention, quality of life, and satisfaction with health care.

We believe that a more effective health care system is possible with the continuous education of health care personnel and the design of an effective platform for discourse among health care professionals. This explains the reason for our aggressive 2015 training campaigns across Nigeria and beyond.Join us as we advance the development of health care management around the globe.

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Quality measurement and management in health care systems