Quality metrics

The use of measures of quality of health care has received increasing attention in recent years. Much debate has centred on their appropriate application, in particular contrasting an ideal model of formative, locally driven improvement with the use of summative measures for performance management and accountability. A range of categorizations of clinical quality indicators are described, along with alternative approaches to their employment in practice. The available evidence on the circumstances in which clinical quality indicators are most likely to lead to quality improvement is summarized. Most controversies over the use of clinical quality indicators tend to revolve around questions of statistical analysis and interpretation. Risks include the possibility of ‘false denigration’ – labelling apparent differences as poor performance when, in fact, they are due to chance variation. Conversely, indicators may sometimes fail to reveal real differences which have been obscured by random fluctuation. The analysis of outcome measures can also be significantly affected by the inclusion of data on patient characteristics, and considerable debate surrounds the appropriate use of risk-adjustment techniques to reduce bias. The NHS is making increasing use of clinical quality indicators, and has recently published the ‘Indicators for Quality Improvement', which seek to make a wider range of quality measures available to clinical staff to support them in benchmarking and local quality improvement.