An evidence-based, structured, expert approach to selecting essential indicators of primary care quality

PLoS One. 2022 Jan 18;17(1):e0261263. doi: 10.1371/journal.pone.0261263. eCollection 2022.


Background: The purpose of this article is to illustrate the application of an evidence-based, structured performance measurement methodology to identify, prioritize, and (when appropriate) generate new measures of health care quality, using primary care as a case example. Primary health care is central to the health care system and health of the American public; thus, ensuring high quality is essential. Due to its complexity, ensuring high-quality primary care requires measurement frameworks that can assess the quality of the infrastructure, workforce configurations, and processes available. This paper describes the use of the Productivity Measurement and Enhancement System (ProMES) to compile a targeted set of such measures, prioritized according to their contribution and value to primary care.

Methods: We adapted ProMES to select and rank existing primary care measures according to value to the primary care clinic. Nine subject matter experts (SMEs) consisting of clinicians, hospital leaders and national policymakers participated in facilitated expert elicitation sessions to identify objectives of performance, corresponding measures, and priority rankings.

Results: The SMEs identified three fundamental objectives: access, patient-health care team partnerships, and technical quality. The SMEs also selected sixteen performance indicators from the 44 pre-vetted, currently existing measures from three different data sources for primary care. One indicator, Team 2-Day Post Discharge Contact Ratio, was selected as an indicator of both team partnerships and technical quality. Indicators were prioritized according to value using the contingency functions developed by the SMEs.

Conclusion: Our article provides an actionable guide to applying ProMES, which can be adapted to the needs of various industries, including measure selection and modification from existing data sources, and proposing new measures. Future work should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as operationalizating measures to be meaningful and interpretable across health care settings.

MeSH terms

  • Aftercare*

Grants and funding

This study was funded by a grant from the Agency for Healthcare Research and Quality (; Grant #5R01HS025982-02) provided to author SJH. The salaries of two of the authors (Hysong, Petersen) were also funded in part by U.S. Department of Veterans Affairs Health Services Research & Development grant # CIN 13-413 awarded to author LAP. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.