Putting Outcome Measurement in Context: A Rehabilitation Psychology Perspective Allen W. Heinemann Northwestern University and Rehabilitation Institute of Chicago This article provides an overview of topics related to health care measurement as applied to medical rehabilitation. Described are conceptual models of health outcome measurement in rehabilitation and their utility for researchers and clinicians, the application of contemporary measurement approaches to rehabilitation outcome measurement, and accrediting organizations’ efforts to implement performance indicators for rehabilitation. The discussion situates participation as a key interest of rehabilitation psychologists and other stakeholders. Reviewed are examples of instruments designed to operationalize participation, advances in measurement theory, and methods that allow outcome indicators to be measured more accurately and easily, including item response theory. This introduction concludes by considering how public disclosure of outcomes can help consumers make more informed choices and help accrediting organizations’ efforts to promote outcome disclosure. The purpose of this article is to provide an overview of key components of health care quality measurement that guide ways of discussing and improving outcomes. The article also describes conceptual models of outcomes in rehabilitation and their utility for researchers and clinicians, situates participation as a key out- come for rehabilitation psychologists, describes the application of contemporary measurement approaches to rehabilitation outcome measurement, and discusses accrediting organizations’ efforts to implement performance indicators for rehabilitation. Table 1 pro- vides a summary of key terms. Key Components of Health Care Quality Measurement Avedis Donabedian (1966) is credited with distinguishing three key components of health care quality management: structure, process, and outcome. Structure refers to a health care organiza- tion’s facilities, equipment, personnel, and administration. Process refers to management procedures, record keeping, diagnosis, treat- ment planning, and treatment delivery. Outcomes refer to the desired benefits of health care efforts. They can be measured with generic or condition-specific instruments; patient satisfaction is often used as a primary outcome indicator. Early evaluations of health care focused on structure and process because this informa- tion was readily available. More recently, health care outcomes have emerged as the focus of attention, given the recognition that good outcomes are the product of well organized and managed health care. Accreditation bodies such as the Joint Commission on the Accreditation of Health Care Organizations and the Commis- sion on Accreditation of Rehabilitation Facilities (CARF) now emphasize outcome measures rather than an exclusive focus on structure and process. Outcome indicators are used increasingly as the basis of quality measures and reflect efforts to improve quality of care and customer satisfaction. The Federal Government’s in- terest in quality measures is reflected in the National Quality Measures Clearinghouse, sponsored by the Agency for Health Care Research and Quality. The Clearinghouse provides a database and Web site on generic and condition-specific health care quality instruments and measure sets (http://www.qualitymeasures .ahrq.gov/). All three aspects of health care deserve attention since a sole focus on outcomes overlooks the power of organizational attributes and provides little direction for quality improvement activities. Consequently, a comprehensive quality measurement system should include indicators of structure, process, and outcome. There is considerable evidence that health care outcomes vary across settings (Kane, 1997; Wennberg, 1982). The current move- ment toward clinical practice guidelines or protocols is predicated on the belief that greater standardization of practice will result in greater quality at lower cost, much as industrial processes have been improved by applying quality management principles (Public Health Foundation, 2001). Empirical demonstration that variations in practice have causal relationships with outcomes has become a distinct quality management focus. Clinicians and researchers are working toward consensus on how best to treat certain illnesses or conditions, owing in part to the work of Patient Outcomes Re- search Teams (Donaldson & Capron, 1991) and clinical practice guidelines funded by the Agency for Health Care Research and Quality and various private organizations (http://www .guideline.gov/). Information about clinical practice guidelines has Allen W. Heinemann, Department of Physical Medicine and Rehabili- tation, Feinberg School of Medicine, Northwestern University, and Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, Illinois. Research reported in this article was supported by the National Institute on Disability and Rehabilitation Research through a Disability and Reha- bilitation Research Project on Medical Rehabilitation (H133A030807). The contributions of Rita Bode, Jennifer Bogner, John Corrigan, Cynthia Harrison-Felix, Gale Whiteneck, and Deborah Wilkerson are acknowl- edged and appreciated. Correspondence concerning this article should be addressed to Allen W. Heinemann, PhD, Rehabilitation Institute of Chicago, 345 East Superior Street, Chicago, IL 60611. E-mail: a-heinemann@northwestern.edu Rehabilitation Psychology 2005, Vol. 50, No. 1, 6 –14 Copyright 2005 by the Educational Publishing Foundation 0090-5550/05/$12.00 DOI: 10.1037/0090-5550.50.1.6 6