A Consumer-Centered Framework For Quality: How Do We Get There From Here?

When buying a car, consumers are able to readily review some critical pieces of information, such as the price of the car; the mileage per gallon; what other owners thought of that model’s reliability; and how the car handles on various road tests.

When it comes to health care, however, consumers aren’t able to easily obtain the few, key summative, consumer-facing measures that could help them understand the quality of their care.

This isn’t because we don’t have quality measures in health care. To the contrary — there are in fact hundreds of measures. But these measures tend to be narrow in their scope (for example, management of diabetes or congestive heart failure, or ensuring that a colonoscopy was done for preventive care) making them hard to connect to a broader understanding of quality. The shift to population-based payment in particular has unmasked the gap in “big dot” measures necessary to capture overall system performance.

Production vs. Consumer Measures

In other words, what we have in health care are numerous “production” measures, but very few “consumer” measures. Production measures, in the case of the car, would be the thousands of things the manufacturer needs to know in order to produce a high-quality car: how efficiently and reliably each and every step in the manufacturing process is completed, how much variance there is in the dimensions of a particular part, or the tensile strength of a particular type of steel, for example.

These two sets of measures—production and consumer—both reflect the quality of the product and both are important. However, they tell us fundamentally different things.

While we have hundreds of production measures in health care, we have very little understanding of the measures consumers want and need. This is not particularly surprising, as quality measures tend to be created by people who are (or relate to) producers of health care, rather than the end users.

Building An Infrastructure For Consumer Engagement In Quality Measurement

Viewing quality measurement through the lens of production and consumer measures presents a deceptively simple and obvious solution: get consumers to develop the measures they want.

Yet in the existing process for quality measure development, creating this consumer-centered measurement system is no easy task. Research conducted by the RAND Corporation with the Center for Consumer Engagement in Health Innovation identified barriers to effective consumer engagement in quality measurement. These include a lack of consumer resources for participation in the measure development process, difficulty in achieving sufficiently powerful consumer representation through the typical model of “multi-stakeholder” representation, and requests for overly technical input.

It’s time for a different approach. The current system for engagement often gives consumers a handful of seats at a very crowded table and asks them to vie with other stakeholders to be heard. Instead, there should be recognition that the role of consumer input is fundamentally different from that of other stakeholders. The engagement process should be redesigned to reflect the distinction between production and consumer measures, with the explicit goal of harnessing consumer voices to craft and shape consumer-centered measures.

For this engagement to be successful, an infrastructure for consumer engagement is needed. Consideration should be given to a consumer network that is constructed around local communities. In these communities, local consumer advocates or leaders could serve as hubs for organizing and engaging consumers. This approach is particularly important to consider when it comes to engaging harder to reach populations like low-income or other marginalized communities, people with behavioral health conditions, and people with a complex illness. This structure would allow consumers to engage and connect with other members in their local community, build peer-to-peer support and tap into a broader set of experiences than just their own. An approach built around consumer-led hubs could also help to sustain consumer engagement, in contrast to the current episodic approach that relies on consumers to be available “on demand” for short engagements.

This infrastructure would serve as the foundation for consumer input into the creation of quality measures that reflect consumer priorities and concerns. With sufficient resources and training, consumer leaders and advocates could help the quality measurement enterprise by shaping the creation of a slate of consumer-oriented measures, as well as to push for their implementation and use. It’s time for a new paradigm in quality measure development, one that focuses on generating consumer-centered measures, rather than proliferating ever more measures of production.

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