How Stakeholder Perceptions of Quality Shape Healthcare Transactions: Insights from Key Decision-Makers Across the Ecosystem.

Goal: In today's healthcare ecosystem, quality measures are theorized to inform the spectrum of healthcare delivery and evaluation, including specific functional areas such as quality improvement, regulation, accreditation, and value-based payment. Yet, the ways in which expectations about quality-real or perceived-shape and inform transactional relationships between healthcare stakeholders have not been well elucidated. We elicited the perspectives of healthcare decision-makers to understand their experiences with quality and how they may influence transactions and strategic alliances.

Methods: A qualitative study incorporating semistructured in-depth interviews conducted with C-suite and D-suite decision-makers in the United States representing a mix of different types of healthcare organizations. Interviewees were asked about organizational culture and strategic priorities, qualities sought in potential business partners, and factors that drive decisions to transact with external partners. Interviews were audio-recorded and transcribed verbatim, and data were analyzed to identify key themes.

Principal Findings: Quality, as an objective measure (e.g., the Healthcare Effectiveness Data and Information Set [HEDIS] or the Consumer Assessment of Healthcare Providers and Systems [CAHPS]), or a subjective assessment, was only one of many considerations that shaped transactional relationships with external healthcare stakeholders. Key informants described a range of factors considered, including partner reputation, alignment of culture and mission, and ability to achieve strategic priorities. While the term quality was broadly used and defined among the key informants, participants often incorporated the term value into their lexicography of quality and felt that value played a more significant role in decision-making. Standardized quality measures can be useful both for prompting investment within organizations and for deciding when to seek the assistance of external parties to help improve commonly collected and reported quality measures. Ultimately, the manner in which quality manifests in real-world practice and operations is not as simple or straightforward as policymakers or quality metrics developers may believe.

Practical Applications: Although there has been significant public and private investment in quality initiatives, including their use in payment and regulatory models, this study elucidates how stakeholders across the healthcare ecosystem assess quality from a strategic operating perspective. We identified a number of key drivers that underpin transactional relationships and that ultimately impact the results of standardized and publicly reported quality measures captured for payment, regulation, and public accountability purposes. While decisions regarding these relationships are internal matters and thus fall outside the scope of regulators, policymakers and regulators need to understand their importance and likely correlation with what is ultimately measured and used for payment, regulation, and public transparency.