The quality of health care is increasingly scrutinized.1 Indeed, the principal message of the Institute of Medicine (IOM) reports “To Err Is Human” and “Crossing the Quality Chasm” was that there are substantial problems with the quality of health care delivered in the United States.2–4 Similar to other medical specialties, emergency medicine (EM) practice is subject to errors and quality concerns.3 The specialty of EM is characterized by high acuity, high stress, increasing patient volume, and rapid decision-making often with incomplete information. These factors, among many others, create obstacles to providing high-quality care in emergency departments (EDs).5
A prerequisite for assessing (and, where needed, improving) the quality of emergency medical care is the ability to measure quality of care. An initial step in this process is the development of care standards.6 Quality indicators involve operational definitions to assess whether care is delivered well or poorly.6 Unlike practice guidelines that strive to characterize the nuances of best possible care, quality indicators set a minimum standard for the care expected from clinicians and health systems.7 Care that does not meet well-constructed quality indicators generally represents low-quality care.
In addition to the organization of care, quality indicators may be based on processes of care (e.g., timely administration of aspirin to a patient with an acute myocardial infarction [MI]) or outcomes of care (e.g., living or dying after an MI).8 Process-defined quality indicators represent actions of providers, while outcome indicators represent the results of the care processes plus the effects of many other factors.9 Most health care quality experts favor process-based quality indicators for four reasons. First, processes of care are often more efficiently measured. Care processes occur at the time of care delivery, while the interval between care and outcomes may be long.8,10 Second, process indicators usually are more sensitive measures of quality, because a poor outcome does not occur every time there is a deficiency in a process of care.8 Third, process-defined quality indicators do not require risk adjustment to the extent that outcome indicators do.11 Fourth, process-of-care indicators typically are amenable to direct action by providers, while outcomes deficits often are more difficult to address. Thus, process-defined quality indicators can drive quality improvement efforts by helping direct attention to specific, correctable areas that need improvement.10,12,13 An ideal set of indicators would be linked to patient outcomes through high-quality research;8,12 however, few important care processes have had each aspect rigorously studied.6,14 Quality indicators, therefore, are typically developed with the contribution of expert opinion.6,12
Quality indicators should target care that has been documented to need improvement. The Assessing Care of Vulnerable Elders (ACOVE) investigators found that vulnerable older persons had substantial deficiencies in care, particularly in areas that require specialized geriatric care techniques.15 Older patients are particularly vulnerable in the emergency medical system.5 EDs are major health care providers for seniors; yet, there has been little development of quality measures for this group of patients. The objective of this project was to develop EM-specific quality indicators for older patients. We used an approach similar to that used by the ACOVE project to develop quality measures dedicated to the needs of older patients seeking care in EDs.