# Developing Balanced Quality Indicators for Monitoring Virtual Care in Ambulatory Care Environments: Modified Delphi Panel Process

## TL;DR

This study created a balanced set of 25 quality indicators to evaluate virtual care in outpatient settings using expert consensus and literature review.

## Contribution

The study introduces a novel, consensus-based framework of quality indicators for virtual care aligned with the Quintuple Aim and NAM domains.

## Key findings

- 140 quality indicators were identified and refined through a 3-round Delphi process to a final set of 25.
- The final indicators cover patient experience, provider experience, population health, health equity, and health system costs.
- 89% of panelists participated in all three Delphi rounds, showing strong engagement and consensus.

## Abstract

While the volume of virtual visits increased with the COVID-19 pandemic, little is still known regarding the quality of virtual visits. Furthermore, there is limited guidance on how best to evaluate the quality of virtual care initiatives.

The objective of this study was to curate a balanced set of quality indicators grounded in the Quintuple Aim quality framework and the National Academy of Medicine domains of quality, including sustainability, to monitor the quality of virtual care in ambulatory environments.

Phase 1 involved curating a list of ambulatory virtual care quality indicators from published and grey literature, along with knowledge user feedback generated through a pre-Delphi survey; these indicators were mapped and categorized to the Quintuple Aim and National Academy of Medicine (NAM) Quality Domains. In phase 2, a 19-member pan-Canadian panel was convened as part of a 3-round modified Delphi panel process to rate and rank the quality indicators. The panel included clinicians, individuals with lived experience with the health care system, policy makers, academics, and administrators. Panelists rated indicators using the Agency for Healthcare Research and Quality measure attributes on a 9-point Likert scale in round 1, followed by a virtual Delphi panel meeting to discuss indicators before round 2 of re-rating, then a final round 3 of ranking which assessed the importance of indicators within each quality domain and subdomain. To address gaps in the literature, novel quality indicators of virtual care were identified and discussed in panel discussions, patient group consultations, and a pre-Delphi survey. For indicator advancement during the rating exercises, 75% or more of the panelists’ responses in the top tertile (scores of 7-9) with a median composite score of 7 or greater was required.

There were 140 quality indicators identified in the literature which progressed through the 3 Delphi panel rounds. There was minimal attrition among Delphi panel members (17/19, 89% participated in all 3 rounds). After round 3, 25 indicators were included in the final scorecard. Aligned with the Quintuple Aim, there are 13 quality indicators on patient experience, 6 on provider experience, 2 on population health, 2 on health equity, and 2 on health system costs.

A balanced set of 25 quality indicators of ambulatory virtual care was developed based on literature and consensus building from knowledge users across the health system. This curated set of indicators will support more comprehensive evaluations of virtual care. Organizations can use the set of indicators as part of a scorecard to compare across jurisdictions, identify priority areas, and ensure their virtual care initiatives are delivering high-quality care based on multiple domains of quality.