Technology Accessibility Quality Measures

What can we learn from healthcare quality initiatives to help us make progress in improving the quality of the technology we rely on for our health and well-being, focusing specifically on measures related to accessibility for people with disabilities?

Comparing Healthcare Providers Based on Quality

In the early 2000s I did consulting work for the Dartmouth Hitchcock Medical Center in New Hampshire. DHMC had data about its performance for different quality measures that it could compare against other hospitals and against the national average. They wanted to make this data available on their website, to help patients and families make informed decisions about where to put their trust and get their healthcare.

I created prototypes for a new section called Quality Reports and evaluated the designs with patients and families. The Quality Reports feature reported comparative data on how well DHMC measured up against the top 10 hospitals and the national average on a variety of diseases, procedures, and cost comparisons.

The measure included what seemed like little things, like “Aspirin at discharge: Percent of eligible patients a prescription for aspirin when discharged from the hospital after a heart attack.” And obvious things, like “Advice for heart attack patients to quit smoking: Percent of eligible heart attack patients who were advised to quit smoking.” And really big and scary things, like “In-hospital heart attack mortality rate: Percent of patients admitted for heart attack who die while in the hospital.”

Since working on the project back in 2003, access to hospital quality data has evolved and expanded. DHMC still publishes the overall quality and safety scores and detailed ratings on patient experience. But today’s best source for this type of data is the Care Compare feature on Medicare.gov, launched in September 2020. The site combines multiple “find and compare” tools to allow people to compare facilities and providers as well as hospitals. DHMC’s quality measures are available, and you can customize comparisons, for example, by comparing DHMC with other acute care hospitals in the region.

Objectives and Structure of Healthcare Quality Measures

The DHMC project and subsequent developments are an outgrowth of the Hospital Quality Initiative (PDF), which developed measures and data collection protocols and provided open access to quality measures using Hospital Compare, which was launched in 2005. The objectives of the Hospital Compare feature are to:

  • Help people make decisions about where to get health care
  • Encourage hospitals to improve the quality of the care they provide

Let’s break down the components of a measure by looking at the three measures from above: aspirin prescribed at discharge, advice to quit smoking, and hospital deaths. The following table includes three elements of a measure: the measure name, description, and rationale for including it as a measure. Many other elements are defined for each healthcare quality measure, but let’s focus on these three.

Table 1: Select Measures for Acute Myocardial Infarction (AMI)
Measure Description Rationale
Aspirin Prescribed at Discharge Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge. Aspirin therapy in patients who have suffered an acute myocardial infarction reduces the risk of adverse events and mortality. Studies have demonstrated that aspirin can reduce this risk by 20% (Antiplatelet Trialists’ Collaboration, 1994). National guidelines strongly recommend long-term aspirin for the secondary prevention of subsequent cardiovascular events in eligible older patients discharged after AMI (Antman, 2004 and Smith, 2001). Despite these recommendations, aspirin remains under-utilized in eligible older patients discharged after AMI (Jencks, 2000).
Adult Smoking Cessation Advice/Counseling Acute myocardial infarction (AMI) patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival. Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit. National guidelines strongly recommend smoking cessation counseling for smokers hospitalized with AMI (Fiore, 2000; Antman, 2004; and Smith, 2001). Despite this recommendation, smoking cessation counseling is rarely provided in eligible older patients hospitalized with AMI (Jencks, 2000).
Inpatient Mortality Acute myocardial infarction (AMI) patients who expired during hospital stay. Mortality of patients with AMI represents a significant outcome potentially related to quality of care. This rate-based indicator identifies an undesirable outcome of care. High rates over time may warrant investigation into the quality of care provided.

We can learn a lot by exploring the many dimensions and connections that make this type of initiative possible, and to ideate how a similar approach might be used to invigorate efforts to improve quality in digital accessibility.

Modeling for Technology Accessibility Quality Measures

Borrowing this model from healthcare, let’s envision a Technology Accessibility Quality Initiative — we could call it “TechAqui” — with these stated objectives:

  • Help people make decisions about where to get accessible technology
  • Encourage tech companies to improve the quality of accessibility in the technology they provide

Sounds great, right? Imagine being able to compare accessibility features of different technology to choose the best, most accessible option, and to watch accessible options grow more numerous as technology companies make accessibility core to their values and operations and become more competent at building to accessibility standards.

For measures, we need to measure what matters — little things, obvious things, and big things. Using the structure above as a model, Technology Accessibility Quality Measures might include:

Table 2: Proposed Measures for Accessible Technology
Measure Description Rationale
Accessibility email address Dedicated email address for accessibility-related communications. A dedicated accessibility email address, such as accessibility@acme.com, provides a communication channel for people who have accessibility-related questions, concerns, and feedback. An accessibility email address allows the organizations to monitor and track reported accessibility issues and take programmatic measures to correct them.
Accessibility webpage Dedicated webpage for accessibility-related communications. A dedicated webpage provides information for people seeking accessibility information. Some accessibility regulations require organizations to post a “public notice” with information about the organization’s accessibility program, including contact information and grievance procedures.
Executive leadership Accessibility program leader with cross-organizational authority and influence. An executive leader can establish and maintain accessibility as a core value, guiding principle, and common practice, requiring individuals within the organization to prioritize accessibility in their work. Other technology quality initiatives benefit from executive leadership, e.g., Chief Security Officer, Chief Privacy Officer.

We have constructed a digital world that largely does not follow accessibility standards. As our reliance on technology grows, so does the urgency to build for accessibility. Inaccessible technology prevents people from essential activities, such as working, learning, getting healthcare, and taking care of others. When we use technology in high-risk contexts, accessibility barriers could cause significant harm to health and safety.

We in the technology industry have a lot to learn from healthcare about how to take our role seriously. A comprehensive set of Technology Accessibility Quality Measures would be a good starting point, helping define quality and motivate professionalism in a field the sorely needs it.

Let me know if you would like to explore this idea further. You can always reach me at sarah.horton@gmail.com or @gradualclearing.

Download slides from #a11yTOConf session, Accessibility Quality Indicators ~ Love Made Visible: Accessibility Quality Indicators #a11yTO 2020 (PPT)

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