QUALITY OF CARE: A FRAMEWORK FOR MEASUREMENT
Measuring efficiency of care An important piece of information on the provision of care is the efficiency of delivering a given level of quality of care, which requires measuring: (1) the actual cost of health care, (2) the share of patients who do or do not receive the correct care, and (3) the cost of providing the optimal level of care. Chapter 7 returns to the concept of the efficiency of effective coverage in more detail. The first task can be accomplished using administrative data such as a health management information system or patient survey data, although any administrative data need to be detailed enough to be able to attribute cost to specific provider-patient interactions. For example, this requires measuring the time different staff spend on a given consultation and attributing the materials used to specific cases. The second and third tasks are more difficult because they require estimating the cost of the provider’s effort and time to deliver the desired quality of care. While the cost of the optimal treatment may be lower in terms of material costs than the treatment that is actually received, due to the frequent provision of nonindicated care, the health worker’s effort will almost always be higher when the optimal level of care is provided. Studies that use knowledge and skill tests (for example, vignettes or observed patient visits when the Hawthorne effect is still present), as well as impact evaluations that use financial incentives to increase provider effort, could be important sources of data for estimating the cost of the “optimal” provision of care in terms of time and effort spent. Standardized patient and other quality of care studies can serve to estimate the share of patients receiving the appropriate care. Understanding the efficiency of care and how it is affected by financial incentives could be a fruitful area for future research.
Conclusions Understanding the extent to which various constraints restrict the provision of high-quality care helps inform policies aimed at improving the quality of health services and health outcomes. For instance, an approach to improving provider effort might be explicitly linking facility or provider payments to results. So-called performance-based financing programs typically pay for quality directly, by paying for specific indicators of process quality, or indirectly, adjusting the total payment according to a broader measure of quality. 49
