United States quality assurance in health care is studied and implemented with considerable intensity. Some countries have followed the U.S. example and developed (or are in the process of developing) their quality assurance programs on the traditional structure-process-outcome model. In a few countries (e.g., the Netherlands and Malaysia), performance indicators and health accounting are dominant elements of the quality assurance programs. Reerink reports that the most important facets of quality assurance in countries he studied are the dominant role taken by health professions in establishing quality assurance systems and the widely held perception of the necessity of health professional leadership for successful quality assurance programs.


Several aspects of the continuous improvement model resemble those of contemporary systems of quality assurance or performance monitoring described a decade or more ago for the health care field. These systems include the bi-cycle concepts of Brown and Uhl (1970) and the health accounting approach of Williamson12 (1978, 1988), both of which have cycles quite analogous to the planning-doing-checking-acting (PDCA) approach. Moreover, both approaches incorporate notions of structure (e.g., organizational factors and high-level accountability), process (e.g., patient care activities), and outcomes (e.g., patient well-being or satisfaction). For instance, both the traditional and the continuous improvement models of quality assurance stress the importance of outcomes (or achievable benefit); Williamson’s health accounting approach, for instance, starts with achievable benefit not being achieved and works back to the process of care. The main distinction is that the latter more explicitly involves patient (i.e., customer) values as a critical element of outcomes. Both approaches also acknowledge the importance of information that links processes to outcome. Thus, in many ways the continuous improvement approach is consistent with traditional notions of quality assurance.

The two concepts depart from each other mainly in five ways. The continuous improvement model, first of all, emphasizes continual efforts to improve performance and value even when high performance standards appear to be met. In the latter case, traditional quality assurance activities would cease or shift attention elsewhere. Second, continuous improvement stresses the evaluation of simple and complex systems from the perspectives of the customers. This has the effect, among other things, of directing attention to the way people and departments in organizations work together and, thus, to sources of variation and multidisciplinary quality-of-care issues that traditional quality assurance approaches might not detect or target for change.

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