Despite rapidly increasing reliance on the public reporting of quality measures, there is little evidence about the relationship between quality measurement and quality improvement, particularly in the ambulatory care setting.3
We found that clinics in groups that focused on diabetes metrics in response to reporting by the collaborative were more likely to implement single and multiple diabetes improvement interventions of all types (patient-, provider-, or system-directed) during any year, compared to clinics that had no focus on diabetes metrics. However, the clinics without experience in diabetes improvement were more likely to implement single interventions, whereas the clinics with experience were more likely to implement multiple interventions.
In contrast, clinics in groups that focused on diabetes metrics but not in response to the collaborative’s reporting were more likely to implement multiple interventions in a year—particularly patient- and system-directed interventions—than they were to implement a single intervention. Overall, there was also a trend toward increased implementation of multiple interventions in all of the clinics in more recent years.
We asked quality directors from four physician groups that participated in the study to comment on why clinics chose to implement single versus multiple interventions in a given year. We discovered that clinics implementing single interventions tended to be in the early stages of quality improvement to improve diabetes care. One quality director commented that, with the group’s participation in the collaborative, its physicians were seeing standard comparative reports on their diabetes quality metrics for the first time. These reports motivated the physicians to “do something,” the director said, but “they just didn’t have the bandwidth to do more.”
Another director noted that several clinics implementing single interventions were “naïve…. They just hoped that they could make a small effort and change the metrics.”
Clinics that implemented multiple interventions sometimes did so in response to the collaborative’s reporting, but often they were participating in large or externally sponsored projects “instigated and led by [their] health system,” one of the directors told us. In one case, clinics had implemented a single physician-directed intervention as a “first step,” but the quality director of that group noted that “we needed broader organizational change to sustain the improvement.” Examples of these externally-sponsored projects included the National Committee for Quality Assurance’s medical home certification initiative, its diabetes recognition program, and the Association of American Medical Colleges’ national chronic care collaborative project.
Public reporting of quality has the potential to change the culture and behavior of an organization in ways that increase its engagement with performance improvement activities.20
However, literature on organizational change suggests that wholesale change is problematic and probably inappropriate, and that limits are set on this change by local systems.21
The fact that clinics with no prior experience in diabetes improvement were more likely to implement single interventions than multiple ones in response to the collaborative’s reporting supports the idea that public reporting may affect quality improvement through incremental organizational change. It may bring organizations off the sidelines to engage in an initial or early-stage improvement activity.
In contrast, organizations that focus on improvement but do not view themselves as responding to public reporting may have already developed an organizational culture in which improvement activities are seen as fully integrated into the fabric of the organization. The existence of such a culture facilitates the implementation of multiple improvement initiatives and permits participation in large, externally sponsored projects.
There is increased interest and activity at all levels in the public reporting of quality in primary care.22
Performance reporting requires substantial time and resources from primary clinicians,23,24
which makes it critical to begin understanding the value of these metrics in improving the quality of care.
Our results suggest that public reporting, along with participation in large or externally sponsored projects to improve quality, increased implementation of diabetes improvement interventions in outpatient clinics. Clinics were also more likely to implement interventions in more recent years compared to previous years. A focus on publicly reported metrics increased the likelihood of implementing a single intervention that might represent an initial or early step in quality improvement, as well as increasing the likelihood of multiple simultaneous interventions by clinics with more experience.
Future research should examine whether and how interventions driven by public reporting affect performance. Ultimately, the results of this study support the development of accountability metrics that meet the goal of “measurement for improvement.”3 (p. 688)
Specifically, our findings support the development of accountability metrics that recognize incremental improvements in the quality of care, rewarding both early and ongoing improvement activities.