Measuring Outcomes in Ambulatory Care.

Benson, D. Measuring Outcomes in Ambulatory Care. Chicago, American Hospital Publishing, Inc., 1992. 192 pages. $49.95 ($39.95 for AHA members).

This excellent effort begins with the premise that an ambulatory health care organization first needs to develop a delivery system that works, and then must develop the ability to know that it works. Measuring the effectiveness of delivered services may be difficult, but it remains the essence of any quality assessment effort. The adoption of quality improvement techniques by health care organizations requires the ability to measure performance against some expected level. Understanding and then developing outcome measures for health care is the natural outgrowth of this effort.

Dale Benson has spent many years developing and refining methods of evaluating ambulatory care and has gained an intimate understanding of the processes by which such care can be improved. In his latest book, Dr. Benson provides a complete guide to understanding, developing, and using ambulatory outcome measures to create the necessary climate to institute legitimate improvement programs.

The ultimate goal of health care is improvement of the patient's health status. Continuous quality improvement methods are built on the use of objective measures of quality. While outcomes are only indirect measures of quality, they nonetheless represent a key element in determining the quality of the care provided. Measuring outcomes permits the organization to develop priorities for its quality improvement activities, better meet patient expectations, satisfy regulatory agencies and clients, and better fulfill its ultimate goal of improving the health care outcomes themselves.

The book is divided into three sections. Part One introduces the topic of ambulatory outcomes and provides the necessary background to both understand and develop outcome indicators. Part Two proposes a classification system that separates these indicators into four categories: disease-specific, general health, patient performance, and patient satisfaction. Ensuing chapters present 15 real-life examples within each category. Part Three focuses on emerging strategies in outcomes measurement.

Developing outcome indicators can be a daunting process. Dr. Benson provides a recipe for cutting through much of the confusion and complexity by presenting a set of questions that frame the process in workable stages. They focus upon defining the scope of services performed, determining which are priority areas, and then deciding what elements can be looked at in those priority areas that would tell how well the organization is performing. This identifies the proper indicators for that organization. The next stages involve identifying what level of function is desired for that indicator, how often the measurement will be made with what data, and who will be responsible for the measurement effort. Dr. Benson's proposed outcomes indicator classification system incorporates the four categories noted above. Disease-specific indicators are outcomes that relate to a particular disease and reflect an actual change in health. Examples would be unplanned admissions following ambulatory laparoscopic procedures, or white cell counts in chemotherapy patients. General health outcomes are measures of the patients' overall quality of life. Examples are the ability to perform activities of daily living and one's social and recreational enjoyment. Patient performance outcomes refer to the patients' response to health care activities. Examples would include patient education efforts and patient compliance with prescribed treatments. Patient satisfaction outcomes have a profound impact on the results of health care. Appropriate indicators include measurements of patient satisfaction with any aspect of health care.

Dr. Benson examines in some depth the assessment of overall health status, believing that it represents the capstone of an ambulatory quality management program. Indeed, improvement of a patient's health status is the paramount goal of any clinician. The history and current state of the art in such general health measures is presented and explained in detail, providing a solid understanding of their role in a quality management program.

In the final chapter, the author explores where he believes outcomes management may be headed. He presents several available outcomes programs and speculates on what is likely to become available over the next few years. Tying outcome into value in health care, Dr. Benson makes a persuasive case for integrating an outcomes measurement program into the organization's strategic planning and marketing effort.

This book is required reading for any physician executives involved in either the supervision or hands-on management of quality improvement in their organizations. Dr. Benson states that his goal in writing this book was to help others organize their quality management activities, making them more rational, less complex, and better able to measure the effectiveness of health care. By this self-imposed standard, he has succeeded admirably.--Mark A. Bloomberg, MD, MBA, FACPE, Corporate Medical Director, Tufts Associated Health Plans, Inc., Waltham, Mass.