Performance Measurement in the Hospital Outpatient Setting. Measures that Are Lacking


Discussants noted that measures are missing in several key areas:

  • ED care: According to discussants, it is critically important to have a robust set of ED measures not only because of the significant role the ED plays in clinical care (“Everything is seen in the ED, one way or another”), but also because the ED is a clearly identifiable part of the hospital outpatient setting (“Everyone can actually agree that the ED is part of the hospital outpatient setting, whereas other areas are more murky and/or variable”). In the context of the ED, there are two main circumstances for which there are a need for measures: (1) the management of patients with a definitive diagnosis, and (2) the management of patients who present with certain signs and symptoms, but for whom a definitive diagnosis has not yet been established. Regarding the former, the small set of ED-specific measures developed by the OFMQ is a good start, according to discussants. Additionally, measures developed for the non-ED, ambulatory setting may be applicable, given use of the ED for routine care by some patients. Regarding the management of patients in the absence of a definitive diagnosis, however, more measures are needed. Additionally, some discussants noted a particular need for ED-specific mental health measures, given that a substantial number of patients may come to the ED for a physical ailment, but may also have mental health issues requiring evaluation and treatment.
  • Cancer: Discussants noted that there are many measures evaluating breast and colorectal cancer care, but significantly fewer, if any at all, for other important cancer diagnoses, such as lung cancer.
  • Specialty care: Discussants said that few measures are available that address conditions requiring specialty care.
  • Follow-up care: Discussants pointed out a need for measures that track the provision of follow-up care. However, they noted that the science is not robust in many areas related to such care (e.g., appropriate follow-up care after procedures, ED visits, and hospitalizations).
  • Coordination-of-care/transitions-in-care: According to discussants, measures are lacking that bridge transitions from inpatient to outpatient settings and also among different outpatient settings (e.g., ED to ambulatory care).
  • Transmission of imaging results: Discussants commented that, for the hospital outpatient setting in particular, facilities in which radiological imaging is conducted should be held responsible for reporting imaging results to the appropriate providers to ensure timely and well-informed care. Measures are needed that track this transmission.
  • Outcomes: Many discussants highlighted interest in tracking outcomes in the hospital outpatient setting, but recognized the challenge created by the fact that multiple factors influence outcomes.
  • Episodes of care: Discussants said that measures are lacking to track entire episodes of care, regardless of setting, rather than “pieces of care” that are delivered in different settings.
  • Efficiency: Discussants noted that there is significant and growing interest in efficiency measures across the health care system. However, to date, there are still not many measures that have been developed, tested, and validated. Discussants pointed out that both the NQF and the AQA have assembled workgroups to address this gap.
  • Patient-centered care: Discussants underscored the importance of patient-centered care and pointed to the CAHPS Hospital, and Clinician & Group Surveys, developed with support from AHRQ, as an excellent source of measures. However, these CAHPS measures are not sufficient, according to those to whom we spoke. In particular, discussants said there should also be measures to assess the reporting of test results conducted in the hospital outpatient setting to patients. Additionally, there is a need for measures related to providing understandable explanations to patients, per at least one discussant who emphasized that institutions should be held responsible for engaging patients “on their level” when providing instructions/education about care and medication use.
  • Patient safety: Discussants noted that existing patient safety measures are being applied primarily in the inpatient hospital setting and they were not aware of safety measures specific to the hospital outpatient setting. However, a number of the existing patient safety measures such as hand washing, medication safety, and a culture of safety are applicable to the care delivered in the hospital outpatient setting and could be adapted for use in this setting.
  • Timeliness: The ED measures developed by the OFMQ address the timing of AMI care in the ED setting, but discussants said more measures are needed that address other diagnoses and other hospital outpatient settings.

Finally, across a variety of types and topics of measures, discussants pointed out the lack of distinction in existing measures between providers ordering a procedure/service, and those delivering care. They said that more attention should be paid to this distinction during the development of measures so that the most appropriate providers are evaluated and held accountable.

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