Assessment of quality of health care.

This paper reviews the relative strengths and weaknesses of outcome and process measures as performance indicators in health care. Differences in outcome may be due to case mix, how the data were collected, chance, or quality of care. Health care is only one determinant of health and other factors have important effects on health outcomes, such as nutrition, environment, lifestyle and poverty. The advantages of process measures are that they are more sensitive to differences in the quality of care and they are direct measures of quality. However, outcome measures are of greater intrinsic interest and can reflect all aspects of care, including those that are otherwise difficult to measure such as technical expertise and operator skill. Outcome indicators can be improved if efforts are made to standardize data collection and case mix adjustment systems are developed and validated. It is argued that this is worth doing only where it is likely that variations in health care might lead to significant variations in health outcome and where the occurrence of the outcome is sufficiently common that the outcome indicator will have the power to detect real differences in quality. If these conditions are not met, then alternative strategies such as process measurement and risk management techniques may be more effective at protecting the public from poor quality care.

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Key words: clinical competence, medical audit, outcome and process measurement (health care), quality assurance

to consider in which circumstances it might be appropriateHigh-profile failures of health care in the UK have kept the to use outcome measures to monitor health care. In orderspotlight on methods to monitor the quality of health services. to do this, it is important to consider the different contextsHot on the heels of the ‘Bristol case’, a ‘once in a lifetime in which this debate is taking place.drama’ [1] in which three doctors were found guilty by the

General Medical Council of ‘serious professional misconduct’ A question of perspectivein relation to the deaths of 29 babies and young children

undergoing paediatric cardiac surgery, came the ‘Shipman An important contextual issue is the purpose for which the case’ [2]. Shipman was a British General Practitioner who performance indicator is to be used and by whom. The aim was convicted of murdering 15 of his patients, although he of using performance indicators may be to: is suspected of murdering many more. A recent analysis suggests that monitoring outcome could have identified sig- inform policy making or strategy at a regional or national nificant deviations from expected mortality rates in both level, these examples [3]. Others have argued that taking such an improve the quality of care of a health care facility, approach might distract from more mundane methods that monitor performance of health care funders such as HMOs, nevertheless may be more effective at protecting patients identify poor performers to protect public safety against poor care [4]. The debate over what are the most provide consumer information to facilitate choice of health useful types of performance indicator to monitor the quality care provider of health care is of international concern [5]. It is simplistic to view process and outcome measures as being in com- At the national level, performance indicators can be used

in two ways; to compare performance between countries andpetition with each other, but there are circumstances where one type of measure is likely to be more useful than the to inform policy within a country. The summary measure of

population health developed by the World Health Or-other. The aim of this paper is to review the relative strengths and weaknesses of outcome measures compared with process ganization, disability-adjusted life expectancy (DALE), allows

direct comparison of the health of countries, which can raisemeasures as performance indicators for health care and so

Address reprint requests to J. Mant, Department of Primary Care & General Practice, Medical School, University of Birmingham, Birmingham, B15 2TT, UK, E-mail: j.w.mant@bham.ac.uk

 2001 International Society for Quality in Health