Defining a Common Framework for Communicating about Quality

Theoretical Background and research questions/hypothesis:  The Affordable Care Act (ACA) places unprecedented emphasis on reporting health care-related information to consumers and other audiences. The National Strategy for Quality Improvement in Health Care (NQS), developed in response to the ACA, defines public reporting initiatives as, “vehicles for consumers to compare costs, review treatment outcomes, assess patient satisfaction, and hold providers accountable.” While public reporting efforts are ostensibly designed for consumers, the decisions about what to report are made by those operating within a professional framework of quality oversight. Most consumer research on public reporting has focused on how to present comparative provider performance information; however, research has consistently found that consumers may have limited choice and context for understanding the underlying problems quality initiatives are intended to address. Moreover, their decisions require information tailored to their personal circumstances. Thus, we sought to bridge the gap between professionals and the lay public by determining ways to engage consumers in questions about health care quality. We hypothesized that framing the discussion around variations in health care quality – rather than provider choice – could move consumers to consider quality issues in broader terms. We explored the potential usefulness of the Institute of Medicine’s (IOM’s) six aims for improvement and the NQS priority domains, both as a conceptual framework for engaging consumers and also as an organizational framework for professionals to use when reporting quality information.

Methods and Results (informing the conceptual analysis): 

Our prior research on consumers’ information-seeking and decision-making behavior regarding publicly reported quality information informed our hypothesis for this study.

We used focus groups to explore consumers’ (1) subjective perceptions of quality, variations in quality, and indicators of quality; (2) response to and understanding of the IOM/NQS quality domains, as related to these perceptions; and (3) reactions to the quality information presented on the Medicare’s Comparewebsites.

From first-hand observations, we found participants discerned a broad array of technical, structural, behavioral, managerial, and systemic factors affecting quality. Most participants understood the concepts underlying the IOM/NQS domains, found them a useful way to think about quality, and related them to their subjective perceptions. Unlike respondents in our prior studies, participants visiting the Medicare Compare sites after these discussions better grasped the information’s purpose and recognized that the content related directly to aspects of quality previously discussed. The specificity of individual measures provided concrete detail that enhanced understanding of the concepts embodied in the IOM/NQS domains.

Conclusions: 

Consumers drew on their personal experience to engage in discussions about health care quality, independent of specific health care decisions they may face. Consumers were drawn to, and understood, the measures included in the IOM/NQS quality domains, regarding them as useful for conceptualizing quality.

Implications for research and/or practice:  Using the IOM/NQS domains to provide a conceptual framework for communicating what professionals mean to convey – or to reframe consumer-oriented quality reporting initiatives – may be an effective strategy for bridging the gap between professionals and consumers and for engaging consumers in public dialogue around health care quality that moves beyond idiosyncratic questions of provider choice.