Every health care profession has an obligation to ask: How do we know if we’re delivering quality care?
Most health professions have spent decades developing quality measures — standardized, evidence-based tools that allow objective evaluation of the safety, effectiveness, and patient-focused nature of care. These measures drive quality improvement programs, inform accreditation, guide resource allocation, and protect patients.
Like other health professions, chiropractic has a responsibility to develop quality measures grounded in scientific evidence and standards of care. Researchers at Palmer College of Chiropractic are leading that work, and a newly published national survey marks a significant milestone in the effort.
Why This Work Matters
Building quality measures is one aspect of moving a profession forward. Valid measures make it possible to objectively see what’s working, strengthen what isn’t and sustain improvement over time. They give organizations offering chiropractic services and accreditors evidence-based tools to evaluate the care provided. And they give patients information about what to expect. Robert Vining, D.C., D.H.Sc., Associate Dean of Clinical Research at Palmer’s Center for Chiropractic Research, recognized the opportunity to develop quality measures and set his team to work on doing so.
A Rigorous, Stepwise Process
The work began with a comprehensive review of clinical guidelines, best practices, and care standards relevant to chiropractic care, transforming recommendations from those sources into a draft set of 70 quality measures. Because these measures were grounded in existing evidence and care standards, they had a degree of built-in validity, but more validation was still needed.
Therefore, the team conducted a Modified Delphi Consensus process, a structured method in which experts independently rate each item across multiple rounds. Researchers convened 46 clinical administrators from accredited chiropractic institutions and integrated care settings. These were people who work with administrative data, who work in environments where quality measures are used, and who carry accountability for the quality of the care their organizations deliver. After their review, 64 measures remained.
What the National Survey Found
With 64 candidate measures, the team then sought to answer a practical question: where do you start? Not every measure is equally feasible to implement, and not every measure is equally important across different practice settings.
To address this, the team conducted a national survey of U.S. chiropractors from different geographic regions and different practice environments, asking them to rate the importance and feasibility of each measure.
Two findings stood out.
- Despite significant variation in where chiropractors practice and how their clinics are structured, respondents ranked the importance and feasibility of measures with a high level of agreement.
- The highest-ranked measures were mostly related to safety (e.g., red flag screening, assessing response to care, referral for osteoporotic fracture). Safe care is the foundation for quality. Without safe care, treatment effectiveness is compromised, and the value of all other dimensions of quality — equity, efficiency, timeliness, patient-centeredness — is significantly diminished.
What Comes Next
Developing measures is only meaningful if they get used. The research team is encouraging health organizations that offer chiropractic services to begin piloting measures, starting with developing the infrastructure and policies needed to support quality care. Once policies and procedures are in place, consider what quality measure data your electronic health record system can provide. The measures deemed most important by practitioners responding to a national survey are described in detail in the team’s latest publication.
The research team is also working on what’s still missing. Patient experience measures help health organizations understand what patients actually experience during care. These are distinct from patient satisfaction, which can be high even when the quality of care is poor. Patient experience measures for chiropractic have not yet been developed. It’s where the team is headed next.
Quality measure development is also never complete. Measures must be continuously reviewed and updated as scientific evidence advances, clinical practices evolve, and feasibility in real-world settings becomes better understood.
This post draws on research published in Chiropractic & Manual Therapies and a Behind the Paper post by Robert Vining, D.C., D.H.Sc., Associate Dean of Clinical Research, Palmer Center for Chiropractic Research.
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