Definitions of quality
There are many proposed definitions for quality of care, and at the same time a lack of an agreed consensus on how to define it. Table 1 presents the currently used healthcare quality definitions in medical literature (12).
Table 1*: Definitions of quality of care
* Reprinted with permission.
The Institute of Medicine’s definition from 1990 indicates that quality is measured as a scale or degree rather than a binary system. This definition refers to health services and by doing this includes all aspects of care. Further, this definition covers the notion that the desired quality outcomes should be general, despite the fact that quality may be assessed by the perspective of an individual or a population. This allows that different perspectives like those of professionals, patients, and public to be taken into consideration. This
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definition also indicates that the link between quality and outcome is rarely causal (increase the likelihood), and that quality of care should be judged relative to current professional knowledge (13). In addition to Institute of Medicine, Avedis Donabedian (14) has played a substantial role in increasing awareness of healthcare quality. He comprehended healthcare quality as the product of two factors; the science and technology of healthcare, and the application of that science and technology in actual practice. He proposed that the quality in healthcare could be characterized by several attributes i.e.
efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy and equity.
In summer 2010, Norwegian Knowledge Centre for the Health Services published and important report entitled “Conceptual Framework for a National Healthcare Quality Indicator System in Norway – Recommendations” (15). In this report a new definition of quality in Norwegian healthcare system was suggested. The new definition is “quality means the degree to which the activities of healthcare services increase the likelihood of a desirable health-related welfare for individuals and population groups, and the services are performed in accordance with current professional knowledge” (translation by Albert Castellheim).
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Dimensions of quality
Like Donabedian, several authors and organizations have described the concept of quality, by using dimensions of quality, in an attempt to defining it. Table 2 summarizes these attempts.
Table 2*: Dimensions of quality of care (12):
* Reprinted with permission.
Efficacy is the ability of the science and technology of healthcare to produce improvements in health when used under the most favorable circumstances.
Effectiveness is the degree to which theoretically available improvements are in reality accomplished.
Efficiency is the ability to lower the costs without decreasing available improvements.
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Optimality is the balancing of improvements in health against the costs of such improvements.
Acceptability is recognition of the wishes, desires and expectations of patients and their families.
Legitimacy is compliance to social preferences as expressed in ethical principles, values, norms, traditions, laws, and regulations.
Equity is coherence with a principle that determines what is fair in the distribution of healthcare and its benefits among members of the population.
Equity is different from equality. Equity is a consideration of fairness where in a given circumstance some individuals within a group with the same medical condition will receive more care based on their different and better ability to benefit the given care.
There is important to note that the definitions of some mentioned concepts like efficiency and effectiveness may vary in different knowledge fields like quality and patient safety, economics, and administration.
Structure, process, and outcome
According to Donabedian, the overall quality in medicine comprises of three areas; structure, process, and result. The industrial nomenclatures for the same concepts are input, throughput, and output.
Structure quality describes the resources available. For instance in an intensive care unit (ICU) it would consist of the design of the unit, rooms, equipments, human resources like nurses and physicians, educational resources and competency, and finally organisation and management resources. Quality standards can be set by national health and regulatory authorities or intensive care societies.
Process quality describes all the events during the hospitalization, from admission to discharge, and includes how things are being done (processes).
Effectiveness of communication, misunderstandings, omissions, timings, and the use of guidelines are important elements in process quality.
Outcome quality describes what the ICU has produced by using its structures and by applying its processes. Important outcome measures are the
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following: mortality in the ICU, mortality at hospital discharge and at 6 or 12 months, quality of life and functional status at 6 or 12 months, severity adjusted mortality rates, ICU readmission rate, nosocomial events (nosocomial infections, accidental extubations, decubitus ulcers), number and severity of adverse events and errors, complications, and patient and family satisfaction (16).
As mentioned above communication is an important element in process quality.
It has been estimated that 85% of errors across industries result from failures in communication. Impaired communication may occur between patient and healthcare professionals, between family and healthcare professionals, in the shift-to-shift report, between units in case of transfer for instance, and between members of healthcare team. There is a need for physicians to be familiar with communication skills and use them properly. Some of these skills are attentive listening, asking questions, paraphrasing, reflecting, explaining, checking understanding, summarizing, concreteness, and structuring. Unclear verbal or written communication is especially common in connection with medications (17).
Quality assurance and monitoring clinical performance
Donabedian describes what he calls “the components of quality” and places
“the care provided by physicians and other providers” at the center of the components of quality emphasizing its outstanding position in health quality.
Care provided by physicians and other providers is comprised of interpersonal and technical aspects. The interpersonal aspect of care deals with patient-practitioner relationship and the technical aspect of it is focused on practitioners’ knowledge, judgment and skills. The knowledge, judgment, and skills of practitioners, and in our case physicians, is one the central themes in this paper.
Donabedian states that one may assure the quality of health (quality assurance) by monitoring clinical performance and improving it when necessary. The necessary steps in this process are as follow: determining what to monitor and priorities in monitoring, selecting approach or approaches to assessing performance, formulating criteria and standards, obtaining the necessary
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information, choosing when to monitor and how to monitor, constructing a monitoring system, and bringing about behavior change (18).