Quality of Care is the degree to which Health Services for
individuals and populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge.
Healthcare is Constantly Evolving (or "Stop the World, I Want to
Physicians, Nurses, other healthcare personnel, healthcare systems (Clinics,
Hospitals, Labs, etc.), national and state healthcare organizations, insurance
and managed care plans are all in a state of evolution. They share the strain
of development in a larger world that is changing at incredible speed. The
changes can be dizzying and frustrating--every part of the system is feeling
Attention to quality is an Important Element in the Evolution of
Nearly everyone involved in the practice of Medicine is highly trained, is
usually very well educated, and is, for the most part, committed to providing
high quality of care. Because of all the changes in healthcare, the ways in
which quality is perceived, pursued, and insured continues to develop.
Historically, much of what has driven the changes in healthcare has been the
need for insuring quality across the entire healthcare system. For an historical
overview of the development of quality, see the Quality Evaluation Timeline.
Click Here For a Larger
Quality in Healthcare
What is Driving Attention to Quality Today?
Bottom line: Scientifically sound
methods for assessing quality exist and should be employed systematically in the
future to guard against a deterioration in quality that might otherwise occur as
an unintended result of organizational and financial changes in the health
OK, So What Exactly is "Quality"?
- Limited Resources
- Changes in Insurance Coverage
- Shift from paternalism to participation / decision making by patient
- Patient demands and expectations
- The Institute of Medicine defines Quality of Care as:
"the degree to which Health Services for individuals and populations
(1) increase the likelihood of desired health outcomes and are
consistent with current professional knowledge."
- "Quality" is one of the major cornerstones of healthcare along with "Access
to Services" and "Cost." Quality has a major influence on Access and Cost.
accessible services are
provided in an
efficient, cost-effective and acceptable manner
that can be controlled by the ones providing it.
You Mean "Control by Others"—What Power Do I Have Anymore?
- Putting it all together, Quality is achieved when:
Traditional patient care has been a very
individual and private affair conducted solely by the MD.
MDs often feel powerless in this evolving system,
and because quality assessment and assurance (and Total Quality–we'll get to
that later) feel invasive and intrusive, it can produce resistance. While that
is understandable, it is not in an MD's (or healthcare's) best interest to stay
stuck in resistance.
While many still long for the traditional practice
of medicine, the changes happening in healthcare mean that only about 15% of
healthcare quality is attributable to performance of individual MDs (or other)
and 85% is due to performance of systems (Deming on Total Quality).
These new realities in healthcare require a new
paradigm: Team vs. Individual approach (traditional MD model). "Team" concept is
new to MDs.
An MD has power in the developing healthcare
system to the extent to which s/he has knowledge (Knowledge = Power). The
knowledge is of his/her performance and of increases in his/her performance
quality (for him/herself and with respect to externally codified guidelines).
This is the 15% of the overall quality that s/he can actually do something
The power is to do what?
Constantly increase the quality of the patient
care s/he delivers.
Gain greater certainty over economic stability.
Maintain sufficient freedom to deal with
uncertainties of patient care.
Gain a greater sense of participation and
proactive influence in institutional development in the future.
Restore a lost sense of the social value of an
Making Sense Out of the "Quality" Talk—What is Involved in Insuring
Over 30 years ago (1966), Avedis Donabedian, MD, looked at both the
historical development of quality in healthcare and at what was needed. He
suggested that quality had been, and needs to be, insured in three key aspects
- FOCUS: Power allows an MD, within his/her own arena, to proactively increase
quality of patient care and to share positive outcomes with influential Managed
Structure (First assessed by Flexner, MD in 1910:
The Flexner Report)
Outcomes (First assessed by Nightingale, RN in
Structure, Process, and Outcomes are measured at the levels of:
||The stable elements of the Health Care Delivery System in a
community that facilitate or inhibit access to and provision of services.
- Community Characteristics (Prevalence of disease)
- Health Care Organization Characteristics (# beds per capita)
- Provider Characteristics (Specialty mix)
- Population Characteristics (Demographics and insurance coverage)
||The interaction between the patient and a provider depends on:
1. Technical Excellence
2. Interpersonal Excellence
Appropriateness of Intervention (health benefit to
patient significantly exceeds the health risk)
Skillfulness of Intervention
(Intervention is humane and responsive to
preferences of the patient.)
||Results of efforts to prevent, diagnose, and treat various
health problems. Some possible outcomes:
Clinical Status (Biologic & physiologic aspects of health)
Functional Status (Physical, Mental, Social functioning--how do disorders
interfere with these? How does disorder affect everyday life?)
- Consumer Satisfaction (Consistency of experience of health care delivery
with expectations and acceptability of experience.)
- Health Service Delivery Systems (Systemic Level)
Each of these levels, in turn, has both an Internal and an External Focus:
WHOA! This is Too Much!
What Can My Small Team Alone do to Improve Our Quality of Healthcare
Focus on Clinical, Internal Quality Assurance, paying attention to the
following Medical Conditions:
- Specific Health Conditions or Services (Clinical Level).
- Highly prevalent conditions with significant effects on Morbidity and
Mortality. Focusing on prevalent conditions provides for a greater number of
cases to be available for review so there is adequate statistical power to draw
- Primary prevention (prevent disease from happening)
- Secondary Treatment (stop progression, accomplish cure)
- Tertiary Treatment (reduce impairment)
- Conditions in which improving quality of service delivery will be
efficacious, i.e., will enhance population health (spend effort in the wisest
- Conditions for which interventions are cost effective (spend money in the
A Paradigm Shift: From "Quality Assurance" to "Total Quality"
Traditionally, Quality Assurance programs have focused on physicians (alone)
and changing physicians' behavior by:
- Conditions for which interventions are under control of health plan or
provider or for which variation can be controlled (a matter of the
non-contamination of the independent variable: the medical or systemic
intervention. That is, it is easier to control how my team performs a treatment
than it is to control patient compliance).
Assessing or measuring performance.
Determining whether the performance conformed to
standards (HEDIS, Clinical Practice Guidelines, HMO, etc.: see below)
Improving performance when standards are not met.
Underlying this approach is the "Bad Apples" view: "find the bad apple and
get rid of it." Such an approach to measuring and insuring quality has,
understandably, led to much resentment and focuses on meeting minimal standards
(then stopping the assessment) rather than on improvement of quality as a
continuous activity and "ethic."
A more mature and developed approach than Quality Assurance (QA) alone is
Total Quality Management (TQM). It uses QA as its first step and seeks to
implement the results of QA into a more comprehensive and continuous effort to
Total Quality is founded upon these principles:
|Quality improvement is a continuous effort by all the
members of an organization to meet and exceed the needs and expectations of the
patients and other customers. The goal is to not merely meet standards of care
or to see them as limits (ceilings) to which we strive, but to exceed these
standards. Performance assessment or measurement (QA) is a necessary step but it
is not the end–it is the first step in a continuous cycle of improving quality
(Continuous Quality Improvement: CQI).
What are Some Techniques I Can Use to Diagnose Quality Problems and Focus
Quality Improvement Strategies?
From the Hospital Corporation of America: FOCUS PDCA:
What About Practice Guidelines, Standards, and "Indicators"?
Clinical Practice Guidelines & Standards of Care
Senior administrative and clinical leaders should
explicitly and actively pursue an ethic of continuous improvement in the quality
of care and service
Processes, not just individuals, should be the
objects of quality improvement. Quality measurement examines variation in
structures, processes, and outcomes and seeks to eliminate detrimental
variation. Processes are complex and are frequently characterized by unnecessary
rework and waste.
Revise personnel management strategy to treat
employees and professionals as valuable resources with a central role in quality
Increase training in multiple areas: supervision,
optimal strategies for procedures, concepts of Total Quality (TQ), communication
skills, elementary statistics and simple analytic, and graphic techniques.
Eliminate work standards and numerical goals
(these stimulate behavior narrowly directed solely at their achievement and are
perceived as maximal attainable levels of performance discouraging appropriate
risk-taking and creativity essential for quality improvement)
new approaches to employee evaluation are
facilitative (based on assumption that people want to do their best and that
variations are process not people problems).
Are systematically developed statements to assist
practitioner and patient decisions about appropriate healthcare for specific
Rely on qualitative reasoning and emphasize
Are written to influence practitioner behavior
Are like "expert opinion"
Require examination of "evidence" and "values"
Must deal with the lack of "best evidence" (for
lack of good studies)
Should include patient preferences (how values
were agreed upon, dates of most recent evidence, and final recommendations)
Should be "graded" according to:
Strength of evidence in the overview
Magnitude of effect
Precision of the estimate (how much does it work?)
Note: The material contained herein is a combination of original
and information quoted and/or modified from:
Al-Assaf, A.F., Schmele, J.A. (1993). The textbook
of total quality in healthcare. Delray Beach, FL: St. Lucie Press
McGlynn, E.A., ; Brook, R.H. (1996). Ensuring
quality of care. In R.M. Andersen, T.H. Rice, G.F. Kominski, Eds., Changing the
U.S. health care system (pp. 142-179). San Francisco: Jossey-Bass.