Perspective:

The following are 10 points to remember about this clinical document:

1. Performance measures (PMs) have been useful for measuring the quality of care, promoting accountability for care, and improving the care and outcomes for patients with acute and chronic medical conditions. The ultimate goal of performance measurement and assessment is to improve patient outcomes, including health status (quality of life, symptom burden, and functional status), morbidity, and mortality.

2. The Institute of Medicine has advocated for ‘shared accountability,’ in which all stakeholders within the healthcare system and all members of the healthcare team(s), including the patient, are responsible for and contribute to the success of any measure. The principles of shared accountability should be considered during the process of developing, analyzing, reporting, and interpreting PMs.

3. Key conceptual issues for shared accountability include: a) shared goal setting; b) shared decision making; c) shared care planning and monitoring, including patient feedback and self-care; and d) assessment of patients’ longitudinal outcomes. Purchasers and payers should work with stakeholders to determine ways to apply principles of shared accountability.

4. As a principle of shared accountability, performance on these measures should be reported back to both clinicians and patients in a timely fashion to facilitate shared care management and achievement of best outcomes. Care must be taken and strategies must be implemented to monitor the impact of shared-accountability measures to ensure that implementation does not lead to adverse patient selection by clinicians or decreased access to care.

5. Traditionally, process PMs have focused on acute conditions and have been cross-sectional, measuring care delivered at a point in time or over a relatively short period of time. However, it is increasingly recognized that a longitudinal timeline should be considered for PMs.

6. It is clear that, to be meaningful, PMs of outcomes require risk adjustment for patient case mix. Thus, when comparing clinicians or healthcare systems, it is important, if possible, to adjust for some of these factors; however, it also must be recognized that the adjustment of PMs for socioeconomic status may obscure important failures to provide the best care to patients with low socioeconomic status.

7. Given that one of the main goals of accountable care organizations (ACOs) is to improve the health of individual patients and populations, longitudinal shared-accountability PMs may provide a mechanism for promoting and improving the quality of patient care under these new healthcare reimbursement and organizational schemes.

8. When considering shared accountability in PMs, one must carefully consider the level of analysis (e.g., individual, practice, system), the time frame of the analysis, the attribution of subjects to a denominator and definitions for the numerator (i.e., what constitutes success), and the different care settings (e.g., inpatient, outpatient, home care).

9. Reward or penalty incentives attached to PMs should account for all factors that influence the measure, including clinician and system performance and patient ability to implement treatment recommendations.

10. The goals of patient-based performance measurement should be to enhance patient and family engagement and achieve better outcomes and care experience. Future research should both examine how the design and implementation of these programs influences their effectiveness, and should assess for potential unintended consequences.