Metrics for Assessing Improvements in Primary Health Care

Abstract

Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include longterm, meaning-and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.

Holding On and Letting Go: A Perspective from the Keystone IV Conference

“…• Building learning communities 44 and communities of solution 45,46 that combine Big Data with deep, on-the-ground relationships to reinvent community-oriented primary care [47][48][49] • Fighting against the widespread adoption of a line-worker approach to mass production that has largely been discredited in manufacturing but that is being applied full bore to public education and to delivering fragmented, depersonalized commodities of health care 50 -56 • Standardizing what is common but not mistaking this for what is important: making room to take time with the particulars 31 of person and place, family, and community • Conducting research not as something that is done to rats, or to people treated like rats, or to subparts of people, and calling that "precision medicine," but as generating relevant new knowledge in partnership with practices, patients, and communities; adding stories to the statistics, narratives to the numbers 57,58 -personalized medicine that requires knowing the person • Integrated care 59 -61 • Embracing the measurement culture at arm's length 16 ; working to assess what is important, empowering those on the front lines to move beyond metrics of central tendency toward personalized care, and making space and time for the important wonders that are beyond measurement • Being the change we want to see 62 I do not know if being countercultural is the proper political stance now. I do know that every day family physicians fly in the face of the fragmenting pressures of greed, anger, and fear, trying to do the right thing for individuals, families, and communities.…”

“…These are the attributes that defy easy metrics that can be centrally commanded and controlled. 16 But these are also the elements that make primary care the cornerstone of an effective, equitable, sustainable health care system 63,71 and that are the system's and society's best hope for achieving the quadruple aim of improved population health, patient experience, sustainable cost, and clinician/staff work life. 72,73 On the first evening of the conference I told 1 of these stories.…”

“…Shiny new rattles enticed: newly won bobbles of prestige, enticements of lifestyle, being paid to "perform" on the sparse commodities of care that can be measured, 16 "transformation" to a way of practicing that would finally garner respect, acceptance, and payment reform. [17][18][19][20][21][22] But we desperately tried to hold onto the ideal-the way of being that gives meaning to family physicians and value to patients and populations-that primary health care is a relationship to be nurtured, not just a commodity to be delivered and optimized, measured and incentivized, bought and sold.…”

Less AND More Are Needed to Assess Primary Care

“…[3][4][5] Our study reveals a significant gap between the universe of what is measured and those elements most critical to good quality primary care, indicating that efforts to reduce measurement burden must be accompanied by efforts to increase the relevance of measures to domains of care affecting population health outcomes.…”

Investing in Relationships and Teams to Support Managing Complexity

“…Measures and support mechanisms need to recognize this complexity, and reward, rather than punish, those who are willing to deal with it. 16 Efforts to support bringing the social determinants of health into health care can help primary care to manage complexity, if these efforts are appropriately resourced. Managing complexity involves investing in the more basic, seemingly simpler levels of care, where providers develop deep understanding and relationships with patients that can be drawn upon for the higher-level primary care functions of integrating, personalizing, and prioritizing care, and abiding with people to advance healing.…”