The three faces of performance measurement: Improvement, accountability and research

Background: In the current climate of public accountability, many clinicians have become uncomfortable with any efforts to create measurement systems. This is, unfortunate because measurements are absolutely essential to efforts for improving the processes of medical care. In Minnesota, work has been conducted with clinicians on measurement pursued for accountability, improvement, and research. Measurement in the improvement process: There are at least three steps in process improvement where measurement is likely to be important: when identifying which problems, or opportunities for improvement, need attention; when the process improvement team is obtaining baseline measurements; and after a new improved process ha's been implemented. Contrast with measurement for accountability: Data for accountability, which are data on outcomes or results, do not usually illuminate how the outcomes were achieved or how processes might be changed to improve them. The measures selected for accountability will be measures that matter to external parties, for example, outcome data on complication rates or costs of care. Contrast with measurement for research: Although objectives and methods of measurement for research make it different from measurement for improvement in many respects, its familiarity to physicians-and its attractiveness to them as scientists-poses a problem for measurement for improvement in health care. Measurement for research is typically too slow, too expensive, and too elaborate to be useful for improving processes in single clinics or hospitals. Summary and conclusions: Experience in guideline implementation and measurement efforts has yielded lessons on how to understand the differences in purposes of measurement.