There is no single, universally accepted definition of health care quality. This is because health care quality involves descriptions of many different, complex aspects of care from several different perspectives. Quality may be measured in terms of outcomes, the end results of care and treatment, or it may be evaluated in terms of process, the way in which the care is delivered. The definition also depends on who is describing quality. Researchers, health care providers, government, and consumers may all assess health care quality differently.
Description
During the early 1980s, Donabedian described high quality care as "…care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process in all its parts…"
In 1984, the American Medical Association (AMA) characterized high quality care as "care which consistently contributes to the improvement or maintenance of quality and/or duration of life." The AMA specified the aspects, or features, of care that should be measured to determine quality. These features included:
Another more concise definition, offered by the Institute of Medicine in 1990, stated that quality is the "degree to which health outcomes are consistent with current professional knowledge."
Today, health care quality is understood to involve many dimensions of care. Measuring quality of care requires relating disease-specific outcome measures to assessments of general, physiological, mental, physical, and social health along with patient preferences and level of satisfaction. Effective measurement of quality enables researchers, practitioners, payors (health plans, insurance companies, government, employers, and health care coalitions) and other stakeholders to identify aspects of quality care and medical practice. It also enables comparisons to be made between institutions, health plans and providers.
Though definitions of quality and how to best measure it vary, there is agreement about the goal of measuring and monitoring health care quality; it is to evaluate and improve both the processes and outcomes of care. Hospitals, health plans, medical groups, and managed care organizations devote resources and personnel to quality assurance and quality improvement initiatives.
Quality assurance and quality management programs include data, utilization, and case management activities. Data management is used to measure and monitor outcomes and identify best practices; it is the foundation for quality improvement efforts. Examples of data used to evaluate the quality of health care delivered to a patient population include:
percentage of patients with congestive heart failure who receive ACE inhibitors
results of patient satisfaction surveys
Utilization management is the process of evaluating the necessity, appropriateness, and efficiency of health care services. Case management is patient-centered action aimed at improving health care delivery and outcomes. Quality management enables health care organizations and providers to identify deviations from accepted standards of clinical practice, measure outcome standards, and support opportunities for improvement.
The most beneficial use of health care quality data is as inspiration and incentive to systematically improve care. When evidence of quality problems is identified, health care providers, professionals, and organizations are better prepared to address and promptly resolve problems.
Viewpoints
The American health care system delivers some of the finest, most sophisticated services and treatment available. Nonetheless, it is possible to identify areas of health care delivery that need improvement. A 1998 U.S. Department of Health Services report, The Challenge and Potential for Assuring Quality Health Care for the 21st Century, described existing problems and successful efforts to address these problems. The report described four key quality of care issues: underuse of services; overuse of services; misuse of services; and variation of services.
Underuse of services, when patients do not receive needed medical care, clearly contributes to higher rates of morbidity (illness) and mortality (death). Overuse of services, when patients receive unnecessary care, can be just as dangerous. For example, prescribing antibiotics to treat viral illnesses, such as colds, not only creates antibiotic resistance but also results in adverse drug reactions and excess costs. Misuse of services refers to errors in health care delivery. These errors range from minor mistakes that have virtually no impact on patients' health to misread laboratory results that delay diagnosis and incorrect administration of medications that may even result in patient deaths.
Variation of services refers to the ways in which medical practice differs between communities and even within a community. For example, studies have found significant geographical differences in the rates of surgical procedures such as Cesarean section. The use of medical practice guidelines, written plans detailing diagnosis and treatment of specific conditions, is considered an effective strategy for reducing variation of services.
All health care providers face pressure not only to demonstrate their ability to effectively deliver health care services but also to document and communicate measures of clinical quality and fiscal accountability. Providers, employers, accreditors (agencies such as the Joint Commission on the Accreditation of Healthcare Organizations and the National Committee for Quality Assurance), and consumers are demanding substantial evidence of quality health care.
Publication of medical outcomes report cards, disease and procedure-specific morbidity and mortality rates has attracted media attention and sparked controversy. Advocates of the public release of clinical outcomes and other health care performance measures believe that despite their limitations, these studies offer consumers a useful way to compare providers.
Others argue that measures such as surgical mortality (death rates resulting from a specific surgical procedure) are incomplete indicators of quality. They feel that the data are often misleading, and unreliable guides for health care decisions. Critics cite problems with data collection that compromise the utility and validity of published reports.
Despite concern about the reliability, validity, and interpretation of data, there is consensus that investigation and disclosure of health care quality data will intensify. Recently, consumer interest has focused on individual providers, such as local hospitals and physicians. Employers, choosing between managed care plans involving the same group of participating hospitals and physicians, are requesting plan-specific information to guide contracting decisions. Companies and employer-driven health care coalitions seeking to compare and choose provider networks rely on physician and hospital-specific quality data during the selection process.
The impact of increasingly frequent, public release of clinical performance measures on consumer and provider decision-making, utilization, and the delivery of health care is not yet fully understood.
Professional implications
Traditionally, researchers, health care professionals, and practitioners tend to view quality in technical terms, such as the skills of the practitioners, the appropriateness of care, and the outcomes (results) of treatment. Health care consumers are more likely to focus on process measures such as waiting time for a scheduled appointment, whether they are treated courteously, the extent to which
they feel health care practitioners have answered their questions, and the nature of the interpersonal relation ships they have with their providers.
Today, there is increasing awareness and appreciation among health care professionals of the importance of patient satisfaction with care. It is generally accepted that when patients are satisfied with the quality of care they have received, they are more likely to adhere to prescribed treatment, return for necessary follow-up, and recover more quickly and completely.
KEY TERMS
Outcomes—Results or consequences of care or treatment.
Process—The steps, actions, or operations used to bring about the desired outcome.
BOOKS
Lee, Philip R., and Carroll L. Estes. The Nation's Health. 5th ed. Boston: Jones and Bartlett Publishers, 1997.
PERIODICALS
Blumenthal, David. "Quality of Care—What Is It?" New England Journal of Medicine 335 (September 19, 1996): 891-894.
Perkins, Sherry B., et al. "Outcomes Management: From Concept to Application." Advanced Practice in Acute & Critical Care 11 (August 2000): 339-350.
Young, Wendy B., et al. "How Wide Is the Gap in Defining Quality Care?: Comparison of Patient and Nurse Perceptions of Important Aspects of Patient Care." The Journal of Nursing Administration 26 (May 1996): 14-20.
ORGANIZATIONS
Agency for Healthcare Research and Quality. 2101 E. Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. <http://www.achpr.gov/>.
American Healthcare Quality Association. 1140 Connecticut Avenue, Suite 105, Washington, DC 20036. (202) 331 5790. <http://www.ahqa.org/>.
