Abstract
BACKGROUND: Clinical-performance measurement has helped improve the quality of health-care; yet success in attaining high levels of quality across multiple domains simultaneously still varies considerably. Although many sources of variability in care quality have been studied, the difficulty required to complete the clinical work itself has received little attention. OBJECTIVE: We present a task-based methodology for evaluating the difficulty of clinical-performance measures (CPMs) by assessing the complexity of their component requisite tasks. DESIGN: Using Functional Job Analysis (FJA), subject-matter experts (SMEs) generated task lists for 17 CPMs; task lists were rated on ten dimensions of complexity, and then aggregated into difficulty composites. PARTICIPANTS: Eleven outpatient work SMEs; 133 VA Medical Centers nationwide. MAIN MEASURES: Clinical Performance: 17 outpatient CPMs (2000-2008) at 133 VA Medical Centers nationwide. Measure Difficulty: for each CPM, the number of component requisite tasks and the average rating across ten FJA complexity scales for the set of tasks comprising the measure. KEY RESULTS: Measures varied considerably in the number of component tasks (M = 10.56, SD = 6.25, min = 5, max = 25). Measures of chronic care following acute myocardial infarction exhibited significantly higher measure difficulty ratings compared to diabetes or screening measures, but not to immunization measures ([Formula: see text] = 0.45, -0.04, -0.05, and -0.06 respectively; F (3, 186) = 3.57, p = 0.015). Measure difficulty ratings were not significantly correlated with the number of component tasks (r = -0.30, p = 0.23). CONCLUSIONS: Evaluating the difficulty of achieving recommended CPM performance levels requires more than simply counting the tasks involved; using FJA to assess the complexity of CPMs' component tasks presents an alternate means of assessing the difficulty of primary-care CPMs and accounting for performance variation among measures and performers. This in turn could be used in designing performance reward programs, or to match workflow to clinician time and effort.