Defining Quality Health Care
In order for Quality Informatics to address the quality of health care, it is necessary to first define the phrase "quality health care". The father of health quality assurance, Avedis Donabedian said that high quality health care consisted of "that kind of 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 of care in all its parts." (Donabedian, A. 1980)
The American Medical Association described high quality health care as that "which consistently contributes to improvement or maintenance of the quality and/or duration of life." (AMA, 1986)
Lohr and her committee were tasked by the IOM to define quality health care and their definition was "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." (Lohr, 1990)
The fact that multiple definitions of health care quality exist is an indication that this is a very complex subject to try to define in a few phrases. Donabedian further described attributes of quality health care, which he called the "Seven Pillars of Quality":
1. Efficacy: the ability of care, at its best, to improve health;
2. Effectiveness: the degree to which attainable health improvements are realized;
3. Efficiency: the ability to obtain the greatest health improvement at the lowest cost;
4. Optimality: the most advantageous balancing of costs and benefits;
5. Acceptability: conformity to patient preferences regarding accessibility, the patient-practitioner relation, the amenities, the effects of care, and the cost of care;
6. Legitimacy: conformity to social preferences concerning all of the above; and
7. Equity: fairness in the distribution of care and its effects on health. (Donabedian, 1990)
In a similar fashion, Maxwell defined the six dimensions of quality health care:
1. Access to services
2. Relevance to need (for the whole community)
3. Effectiveness (for individual patients)
4. Equity (fairness)
5. Social Acceptability
6. Efficiency and Economy (Maxwell, 1984)
One of the most widely accepted definitions of quality healthcare was offered by the Institute of Medicine in their 2001 “Crossing the Quality Chasm” report (IOM, 2001). They outlined six dimensions of healthcare quality:
1. Safe - Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.
2. Effective – Integration of the best research evidence with clinical expertise and patient values, avoiding under-use of effective care, and over-use of ineffective care.
3. Efficient - Care should be given without wasting equipment, supplies, ideas, and energy.
4. Timely - Waiting times should be continually reduced for both patients and those who give care. In addition to emotional distress from long waits, physical harm may result, for example, from a delay in diagnosis or treatment that results in preventable complications.
5. Patient-Centered - Encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.
6. Equitable - Care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.
With multiple dimensions and attributes ascribed to quality health care, it is of note that physicians themselves tended to judge the quality of care on the basis of the technical sophistication of the health care delivered, and placed an emphasis on the quality of the interaction between the physician and the patient.(Blumenthal, 1996)
Measuring Structure, Process, Outcomes
The many descriptions and factors involved in producing quality health care makes it difficult to determine which of these attributes or characteristics should be assessed. A seemingly natural candidate for measurement would be treatment outcomes. After all, outcomes are usually not debatable when considering whether a patient lived or died, recovered, or remained impaired. Because outcomes are rarely subject to interpretation, measurement of outcomes is considered to be desirable. (Donabedian, 1966)
However, there are limitations to studying treatment outcomes. The application of medical science to a problem may or may not result in the best outcome for that patient. A patient may not receive all of the benefits that were anticipated for a treatment. In addition, measuring the patient as being among the survivors for a given condition can lead to faulty assumptions if the person survived, but was otherwise severely impaired. The measurement of the outcome of survival alone would not produce reliable information. (Donabedian, 1966)
Some treatment outcomes take years to come to fruition, which may not be taken into account at the time that the quality assessments are being made. Multiple non-medical factors may also influence outcome. When assessing outcomes it is necessary to make sure that the non-medical impacts are accounted for, holding as many external variables constant as possible. (Donabedian, 1966)
Donabedian did believe that outcomes were the most effective measures of the quality of medical care, but he also focused on the process of delivering medical care. The more subjective measures of process involve the interaction between the health care provider and the patient. Judgments are made as to the quality of the history, physical exam, the differential diagnosis, the treatments ordered, as well as technical competence in procedural activities, such as surgery. Measuring these processes are difficult and more subjective than outcome measurement, but processes are important because they indicate whether or not quality medicine is being practiced.
While Donabedian focused primarily on outcomes and processes, the setting in which health care was delivered was also an obvious component of the delivery of quality health care. Measurement of the facilities, the qualifications and numbers of the staff, the presence or absence of certain equipment, and even hospital administration was combined into what Donabedian called the "assessment of structure". The problem is that it does not automatically follow that having good facilities and staffing results in high quality health care, nor does the absence of certain equipment indicate that health care is not of high quality. However, the measurements of structure involve factors that are more tangible and concrete than processes, and can be more easily evaluated.
1. American Medical Association, Council of Medical Service. Quality of care. JAMA 1986;256:1032-1034.
2. Blumenthal, D. (1996). "Quality of Care--What is It?-Part One of Six." New England Journal of Medicine 335(12): 891.
3. Donabedian A. Explorations in quality assessment and monitoring. Vol. 1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press, 1980.
4. Donabedian, A. (1966). "Evaluating the quality of medical care." The Milbank Memorial Fund Quarterly 44(3): 166-206.
5. Donabedian, A. (1969). "Quality of care: problems of measurement. II. Some issues in evaluating the quality of nursing care." American Journal of Public Health 59(10): 1833.
6. Donabedian, A. (1990). "The seven pillars of quality." Archives of Pathology & Laboratory Medicine 114(11): 1115.
7. Institute of Medicine. (2001). "Crossing the quality chasm: A new health system for the 21st century."
8. Larson, J. S. and A. Muller (2002). Managing the Quality of Health Care. Journal of Health & Human Services Administration, Southern Public Administration Education Foundation. 25: 261-280.
9. Lohr KN, ed. Medicare: a strategy for quality assurance. Washington, D.C.: National Academy Press, 1990. Maxwell, R. (1984). "Quality assessment in health." British Medical Journal 288(6428): 1470-1.
10. Maxwell, R. (1984). "Quality assessment in health." British Medical Journal 288(6428): 1470-1.
Submitted by William Hogg