Different purposes of quality measurement and users of quality information

It is useful to distinguish between two main purposes of quality measurement:

The first purpose is to use quality measurement in quality assurance systems as a summative mechanism for external accountability and verification. The second purpose is to use quality measurement as a formative mechanism for quality improvement. Depending on the purpose, quality measurement systems face different challenges with regard to indicators, data sources and the level of preci-sion required.

Table 3.1 highlights the differences between quality assurance and quality improve-ment (Freeman, 2002; Gardner, Olney & Dickinson, 2018). Measureimprove-ment for quality assurance and accountability is focused on identifying and overcoming problems with quality of care and assuring a sufficient level of quality across providers. Quality assurance is the focus of many external assessment strategies (see also Chapter 8), and providers of insufficient quality may ultimately lose their licence and be prohibited from providing care. Assuring accountability is one of the main purposes of public reporting initiatives (see Chapter 13), and measured quality of care may contribute to trust in healthcare services and allow patients to choose higher-quality providers.

Quality measurement for quality assurance and accountability makes sum-mative judgements about the quality of care provided. The idea is that “real”

differences will be detected as a result of the measurement initiative. Therefore, a high level of precision is necessary and advanced statistical techniques may need to be employed to make sure that detected differences between providers are “real” and attributable to provider performance. Otherwise, measurement will encounter significant justified resistance from providers because its potential consequences, such as losing the licence or losing patients to other providers, would be unfair. Appraisal concepts of indicators for quality assurance will usu-ally focus on assuring a minimum quality of care and identifying poor-quality providers. However, if the purpose is to incentivize high quality of care through pay for quality initiatives, the appraisal concept will likely focus on identifying providers delivering excellent quality of care.

By contrast, measurement for quality improvement is change oriented and quality information is used at the local level to promote continuous efforts of providers to improve their performance. Indicators have to be actionable and hence are often more process oriented. When used for quality improvement, quality measurement does not necessarily need to be perfect because it is only informative. Other sources of data and local information are considered as well in order to provide context for measured quality of care. The results of quality measurement are only used to start discussions about quality differences and to motivate change in provider behaviour, for example, in audit and feedback initiatives (see Chapter 10). Freeman (2002) sums up the described differences between quality improvement and quality assurance as follows: “Quality improve-ment models use indicators to develop discussion further, assurance models use them to foreclose it.”

Different stakeholders in healthcare systems pursue different objectives and as a result they have different information needs (Smith et al., 2009; EC, 2016). For example, governments and regulators are usually focused on quality assurance and accountability. They use related information mostly to assure that the quality

of care provided to patients is of a sufficient level to avoid harm – although they are clearly also interested in assuring a certain level of effectiveness. By contrast, providers and professionals are more interested in using quality information to enable quality improvement by identifying areas where they deviate from sci-entific standards or benchmarks, which point to possibilities for improvement (see Chapter 10). Finally, patients and citizens may demand quality information in order to be assured that adequate health services will be available in case of need and to be able to choose providers of good-quality care (see Chapter 13).

The stakeholders and their purposes of quality measurement have, of course, an important influence on the selection of indicators and data needs (see below).

While the distinction between quality assurance and quality improvement is useful, the difference is not always clear-cut. First, from a societal perspective, quality assurance aims at stamping out poor-quality care and thus contributes to improving average quality of care. Secondly, proponents of several of the strategies that are included under quality assurance in Table 3.1, such as external assessment (see also Chapter 8) or public reporting (see also Chapter 13), in fact claim that these strategies do contribute to improving quality of care and assuring public trust in healthcare services. In fact, as pointed out in the relevant chapters, the rationale of external assessment and public reporting is that these strategies will Table 3.1 The purpose of quality measurement: quality assurance versus

quality improvement.

Quality Assurance and Accountability Quality Improvement Focus Avoiding quality problems

Verification and assurance Measurement oriented

Learning to promote continuous improvement Change oriented

Rationale Provide external accountability and renew

legitimacy Promote change and improvement in care

quality Locus of power

and control External managerial power Internal professional authority Culture Comparisons in order to take summative

judgements on care quality League tables

Blame and shame

Comparisons in order to learn from differences and encourage improvement

Informal benchmarking to promote discussion and change

Precision

required High precision

Use of statistics to identify “real” differences

Lower precision Epistemology Empirical

Statistical validity and reliability important

Interpretative

Use of other data sources and local information to provide context

Source: authors’ compilation based on Freeman, 2002 and Gardner, Olney & Dickinson, 2018

lead to changes within organizations that will ultimately contribute to improving quality of care. Clearly, there also need to be incentives and/or motivations for change, i.e. while internal quality improvement processes often rely on profes-sionalism, external accountability mechanisms seek to motivate through external incentives and disincentives – but this is beyond the scope of this chapter.