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- Defining Quality of Care Jo Harris-Wehling One of the major decisions of the Institute of Medicine (IOM) commit- tee was to adopt a definition of quality of care. Discussions about quality assurance strategies have been shaped (and sometimes complicated) by defi- nitions of quality of care. In the early stages of the committee's work, frequent reference was made to the meaning of quality of care and how a definition might guide the committee's later work. To facilitate the committee's debate about the definition it might ultimately adopt, study staff compiled and analyzed many available definitions of quality of care. This chapter documents that analysis and presents the committee's final definition, which became a focal point for the committee's report. METHODS During the study a large number of definitions of quality of care and sets of parameters that should be considered in defining quality were assembled. Definitions in this context are statements that assert what quality of care is according to the organization or individual proposing the definition. By contrast, the sets of parameters are collections of concepts that the organi- zation or individual believed should be included in any definition. For ease of exposition in this chapter, however, we will refer hereafter to both types of statements simply as definitions. Most of these definitions were submitted to the study through the public hearing testimony; other sources include site visits, focus groups, publica- tions, and a commissioned paper (Palmer and Adams, l988~. Staff re- viewed about 100 definitions (more precisely, 50 definitions and another 50 sets of parameters). The Appendix gives excerpts from 52 of these defini- tions that are used as examples in this chapter. Numencal citations to the list are given as superscripts immediately following the examples. 116

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DEFINING BUMS OF Cam 117 A preliminary analysis of the definitions yielded 24 dimensions or con- cepts that could be used to classify elements of these 100 definitions. This first-round analysis gave a sense of (1) the key terms used by others (such as use of the term "patient"), (2) the variations in terms applicable to a given dimension (such as patient versus consumer or client), and (3) the specific combinations of dimensions that tended to appear in this material. For the main analysis, staff retained 18 dimensions (Table 5.1~; the deci- sion about which dimensions to keep was made more on the basis of quali- tative judgment than on quantitative findings, such as frequency of mention. First, we combined cost-effectiveness and resource constraints, which were initially considered as separate dimensions. Second, we combined two as- pects of accessibility to care. Finally, four preliminary dimensions (refer- ence to a particular setting such as inpatient or home health care; generic reference to outcome; generic reference to process and outcome; and ge TABLE 5.1 Quality Dimensions and Frequency of Occurrence in 100 Definitions of Quality Dimensionsa Frequency of Occurrence Scale of quality Nature of entity being evaluated Type of recipient identified Goal-oriented Risk versus benefit tradeoffs Aspects of outcomes specified Role and responsibility of recipient asserted Constrained by technology and state of scientific knowledge Technical competency of providers Interpersonal skills of practitioners Accessibility Acceptability Constrained by resources Standards of care Constrained by consumer and patient circumstances Documentation required Continuity, management, coordination Statements about use 22 21 24 15 10 12 16 16 34 30 30 27 21 13 13 6 3 The first 8 dimensions were explicitly incorporated in the committee's defini- tion. They are given in the order of their appearance in that definition. The remaining 10 dimensions are listed in descending order of the frequency with which they occurred in the 100 definitions analyzed.

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118 JO HARRIS-WEHLING neric reference to structure, process, and outcome) were dropped because the analysis yielded little evidence of their importance as independent con- cepts in this context. In the following discussion we use specific examples from the Appendix. The final section of this chapter discusses the definition of quality of care adopted by the study committee and identifies the dimensions explicitly incorporated in its definition. KEY DIMENSIONS USED BY SEVERAL GROUPS IN DEFINING QUALITY The first 8 dimensions discussed in this section are those ultimately included in the committee's definition. They are discussed in the order in which they appear in that definition. The remaining 10 dimensions are discussed in descending order of the frequency with which they occurred in the 100 definitions analyzed. A Scale of Quality The dimension of scale can be used in multiple ways. It can indicate a commitment toward excellence and toward continuous improvement. Scale can indicate a belief that assessment methodologies can, or should be able to, distinguish gradations of quality. Scalar terminology can be used in a definition to distinguish superior quality care from minimal levels of ac- ceptable care, a distinction relevant to the different objectives of internal quality assurance systems and external regulatory efforts. A definition with- out a scale dimension could imply that quality is a level of care only above the unacceptable (disqualify) and that no distinction can (or should) be made between high, middle, or low quality. Examples of language used in definitions that include the scale dimen sion include the following: "The degree of adherence to . . . ,,2 "Level of excellence produced . its "The highest quality . . . is that care that best achieves ,,8 "Quality of care is understood to be Me highest scientific care "37 "Achieving quality means the continuous improvement of services . . ,~S2 The Nature of the Entity Evaluated, or the Quality of What? Terms such as health care, medical care, and patient care are frequently used interchangeably. Some individuals and groups, however, perceive

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DEFINING QU~ OF Cal 119 significant differences among these terms. For instance, the term "health care" may imply a greater breadth of services (and outcomes) than does the term "medical care." Donabedian (1988) stated that a relationship exists between the specific elements used to define quality and the specific subject being assessed. The subject could be (1) the performance of the practitioners, (2) the care re- ceived by patients, or (3) the care received by communities. The definition of quality (and the subsequent assessment of that quality) thus becomes narrower or more expansive, depending on how narrowly or broadly one has defined the concepts of health and care. Examples of the terms used for this dimension include the following: "Criteria for quality of medical care: . . . ,,12 " . . . health care services . . . ',~8 20 "Quality health care . . . ',23,24,25,30,31,33,39,46 "Quality is a variety and intensity of humane treatment modalities . . . ,,26 "Quality patient care is "28 "Care that is medically appropriate ,,32 Type of Recipient Who is the recipient of the care for whom a definition of quality is developed? Is it an individual or a population, or both? And what shall be the precise term used? Individual-specific terms used in quality definitions are patient, customer, consumer, elderly individual, and Medicare beneficiary or enrollee. Popula- tion-specific terms treat these individuals as groups or subgroups but could also be expanded to include terms such as society, societal well-being, and public health. Quality definitions that focus on process and structure di- mensions rather than outcome dimensions frequently do not refer to a re- cipient of care. "Patient" is by far the most frequent term used to describe the recipient in the definitions we reviewed. The term "population" is used by Palmer and Adams (1988~ and in the 1974 IOM definition.~4 The American Nurses Association43 uses the term "consumer" as do the Pharmaceutical Manufac- turers Associations and the American Diabetes Association (ADA).= The ADA also uses the term "patient" in its definition. The Office of Technology Assessment (OTA)36 uses the term "patient" in their quality definition, although they frequently use the term "consumer" in their recent report on quality (OTA, 1988~. In that report, OTA explic- itly notes that it does not evaluate the quality of the entire U.~. health care system and that it excludes cost and efficiency considerations. The report

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120 JO HARRIS-WEHLING focuses instead on the quality of medical care provided by hospitals and physicians to individual patients. The term "consumer" connotes very different things depending on one's perspective. Compared to the term "patient," it can imply more active participation in and responsibility for one's health care. It is in this active context that OTA uses the term "consumer." Others may find the term "consumer" distasteful, associating it with perceived negative aspects of the commercialization of health care and the marketing of quality. Goal-Oriented Care According to Steffen (1988), quality is the capacity of the elements of care, such as structure and process, to achieve a goal, such as to improve outcomes. The explicit or implicit goals of a health care encounter (or a long-standing provider-patient relationship) determine to a great extent the dimensions or properties that will be used to assess the quality of that encounter or relationship. Health care goals differ depending on whether they emanate from government, patients, administrators of hospitals or other facilities or agencies, health care practitioners, or other participants in the health care system such as third-party payers. In many situations, health care goals are jointly developed among several parties. Not surprisingly, therefore, goals that may be embedded in a definition of quality will differ depending on what parties are involved in developing the definition. Not all goals of patient care are technical or scientific in nature. Non- medical goals such as patient satisfaction and consistency with patient pref- erences are considered by many to be of great importance and a critical dimension of quality care for the elderly. Several definitions consulted in this analysis are fairly specific regarding the goal dimension, which in essence describes an action with a specific aim such as "helping a patient to maintain independent living." Among them: " . . . High quality care deals with the physical, emotional, mental and spiri- tual or meaningfulness dimensions of life, and tries to help the patient inte- grate all of these areas.''1 " . . . helping the elderly individual maintain an independent existence for as long as he or she can."4 " . . . either increases or at least prevents the deterioration in health status . . .' 6 " . . . achieve the health care goals that are determined by the preferences and values of those patients and populations who receive it.',9 " . . . make health care more effective in bettering the health status and satisfaction of a population, . . "14 .

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DEFIlIING BUMS OF Cam " . . . selection of the best therapeutic option, be it medical, surgical, psycho- social or environmental for art individual patient . . . "25 . . . produce the optimal possible improvement its the patient's physiologic status, physical function, emotional and intellectual performance and com- fort . . ,,42 "All attempts to define and evaluate quality will fail until all care and services are provided and based on the patient's values and goals.''S Risk Versus Benefit Tradeoffs 121 This dimension acknowledges that regardless of the benefit expected from health care, all health care carries some risks: risks of side effects of treatment; risks of poorer-than-expected outcomes; and risks of unexpect- edly poor outcomes. The probabilities of risks and benefits can be forecast more accurately for some health care services than for others. For any given health care service, the ease of predicting probabilities will be greater for some risks and benefits than for others. Predicting the degree of risk or harm in relation to benefit-or net benefit is also easier for some patients and services than for others. This dimension implies that a net good or net benefit probability stan- dard has been adopted. Thus, if this dimension were included in a quality definition, quality assurance might allow for some differences in outcome if the appropriate parties were informed of options and the respective risk implications before making health care decisions. This dimension may be stated in various ways. "The degree to which patient care services increase Me probability of de- sired patient outcomes and reduce the probability of undesired patient out- comes, . . . 'a " . . . Contraindicated treatments avoided (medical) and/or lowest feasible incidence of preventable complications." "Quality of health care is that kind of care which is expected to maximize an inclusive measure of patient welfare after one has taken account of the bal- ance of expected gains and losses that attend the process of care in all its parts." . ~. " and with miriimal risk of malting the patient worse; . . . ,~6 Aspects of Outcomes Specified or Not Some definitions refer quite generically to outcomes, sometimes called benefits. Other definitions refer to specific dimensions of health, presuma- bly to underscore the multi-faceted nature of good health or to emphasize a

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122 JO HARR]S-WEHLING particular domain of health status. Still others strike a middle ground, . using terms such as functioning or health status. Generic terms include the following: anticipated outcome,2 independent existence,4 desired patient outcomes,7 36 improved health,~ inclusive mea- sure of patient welfare, level of well-being,30 and clinical outcomes.3844 Examples of terms for somewhat more specific outcomes are as follows: least morbidity and mortality in the population,5 highest level of function- ing,~8 social and psychological well-being,34 and outcomes that are optimal in arresting disease or restoring function.24 42 Finally, one of the more detailed phrases about outcomes refers to the physiological status, physical function, emotional and intellectual performance, and comfort.2i Role and Responsibility of Recipient Asserted This dimension, if present in a definition' implies that the recipient is more than a passive party. The types of responsibilities differ depending on whether the recipient is an individual or a population. In both cases, how- ever, the dimension asserts active participation in the health care process. Many of these participatory elements relate to patient information, informed consent, and active decision making. This dimension appears in definitions in several ways: " . . . arid pies to help the patient integrate all of these areas.") " . . . with the responsibility of achieving quality dependent on the provider's skills and the time talcen to deliver fully the tools (both cognitive and motiva- tional) by which the consumer affects the necessary actions."22 "Quality health care should be . . . informed patient consent."25 "Quality is . . . with acceptable risk to the patient . . . ,,26 "High quality care is first, care that is desired by all informed patient; . . . "35 " . . . It should be reflective of the patient's value system, . . . "37 " . . . seek to achieve the informed cooperation and participation of the patient in the care process and in decisions concerning that process . . . ,,42 Constrained by Technology and the Existing State of Scientific Knowledge This dimension, if incorporated into a quality definition, accepts the lim- its on the achievable level of quality care imposed by inadequate knowledge of the effectiveness of many technologies and the vast domains of health care science yet unexplored. These constraints affect the quality of care achievable by even the most technically competent practitioner (a dimen- sion discussed next). This dimension implies that quality care will also be

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DEFINING QUALITY OF CARE 123 delivered in a manner consistent with the best wisdom available and that the state of that wisdom is dynamic. Examples that include this dimension are as follows: " . . . based on the best knowledge derived from science and the humani- ties, . ,'5 "styli health rOrD ~s7;th;~ the ~ ~ l;_;t^~;~^ I ~1 ~ hi_ ~ ~-~ ,&_~& _~ . . . ~1 ~ ~UtI~llL l~l=L~Ll~l~ U1 lil~Ul~= ~1~11~. " . . . based on accepted principles of medical science and the proficient use of appropriate technological and professional resources . . . ''42 Technical Competency of-Practitioners and Providers This is a traditional dimension of quality. It includes scientific knowl- edge and cognitive, manual, and perceptual elements. Corporate manage- ment skills might be enfolded in it to recognize in a sense-the formal organized health care delivery system as a provider. The concept of a practitioner having fidelity to a community of patients might also be in- cluded. Examples of this dimension (and in some cases the next dimension on interpersonal skills) are as follows: "A well-trained, competent, and experienced physician plus a patient who has confidence in his or her physician."3 " . . . quality of care consists of two components: 1) the selection of the right activity or task or combination of activities, and 2) the performance of those activities in a manner that produces the best outcome.''6 " . . . the degree to which adequate therapy is based on an accurate diagnosis and not symptomatology."~2 "Quality of care = f (technical care + art of care + technical and art interac- tion)."~7 "Quality is the best technical rendition of the best options selected for a specific patient with the patient's consent, delivered with the utmost compas- sion and respect."29 " . . . care that is based on the application of the sound judgment of the appropriate professionals involved, applied to the specific individual concerns and needs of the patient; and . . . that is agreed upon arid carried out in a relationship of mutual trust and respect."35 Interpersonal Skills of Practitioners This dimension of quality acknowledges a humanistic element of health care in addition to the science of medicine. The trusting relationship be- tween the patient and the health care provider (perceived by many to be the

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124 JO HARRIS-WEHLING touchstone of high-quality care) evolves through the application of this . . . almenslon. In addition to those examples provided earlier, this dimension might be worded in the following manner: " . . . Good medical care maintains a close and continuing personal relanon- ship between physician d patient . . . "at " . . . be provided with sensitivity to the stress and anxiety that illness can generate, and win concern for the patient's overall welfare; . . . ',42 Accessibility From both the community and the individual perspectives, ease of access and equality of access are important dimensions. Accessibility does not have the same meaning for everyone, however. It can mean care that is needed, wanted, sought, obtained, covered by a third-party reimbursement system, or approved by a managed care plan. The particular meaning of access may be clarified in the definition. "Encompass adequate means for providing access of the sick to medical care . . . " . . . concerns regarding quality of care go beyond only whether those indi- viduals actually receiving care are receiving 'good care'. Quality of care also encompasses whether the level and scope of benefits involved adequately take care of the entire health care needs of the individual . . . t,4S " . . . these services should be easily accessible to all patients without barriers of any type.',46 Acceptability This dimension usually refers to consumer or patient satisfaction with the health care provider, but it can also apply to the satisfaction of a deci- sion-making entity with providers. For instance, an employer-purchaser might use selective contracting as a mechanism to denote its satisfaction with providers. From a similar perspective, the Medicare program "ac- cepts" a hospital as a satisfactory provider of quality care if the hospital meets the conditions for participating in the Medicare program. Some experts draw a close parallel between the goal-oriented dimension of quality and the acceptability dimension. A patient (or payer) enters into a health encounter with a set of expectations or a goal, which may or may not be realistic from the perspective of the health practitioner; that goal (implicitly) becomes the measurement tool to determine the acceptability of or satisfaction with the encounter. The acceptability dimension in quality definitions is applicable usually to outcomes of the health encounter, al

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DEFINING QUALITY OF CARE 125 though most assessment tools for measuring patient satisfaction also in- clude process and structure variables. Examples in the definitions that indicate acceptability as a dimension of quality are as follows: " . . . improved health and satisfaction of a population . . . "A " . . . management designed to satisfy the overall needs of the patient . . . "13 " . . . satisfy the reasonable expectations of both providers and pa- tient~s) . . . "~9 " . . . which is perceived by patient and his/her personal community to be caring, competent, and effective . . . ,,28 "A definition of quality . . . must address . . . whether patients are satisfied."4 "(lil~litv Of race- inrillA^o It; tat; ~,~ ~ ~ ~ ~ - a_ _ ~,_~A^_J ~^ ~ ~ ~<~ ~ O~LlOt~L~Vll WIlI~ll 1~ a l~l~LlUll U1 degree to which their service expectations are met.',47 " . . . to meet the needs and expectations of the patients, the physicians, the payers, the employees, and the communities we serve."52 Constrained by Resources One major controversy that often arises during efforts to define quality of care focuses on resource availability (usually monetary) and whether the gradations or scales of quality can fluctuate depending on the resources available. If a dimension of resource constraints is used, optimum care, rather than ideal care, can be an acceptable standard of quality. The "social optimum" approach identifies the most efficient means for providing what- ever level of care society determines is to be available. This stands in contrast to "ideal care," which accepts no restrictions on the availability of care-even very expensive health services-as lone as some marginal net benefit to the patient is likely O ~ . ~A A ~ e. ~ , The social optimum standard is usually determined by society; is defined in operational terms rather than explicit budgetary limitations; and, in most cases, is consistent with a principle of distributive justice. This standard may conflict with professional standards of care, which are rarely defined in terms of economics; professional standards of care honor the principles of beneficence and autonomy more so than the principle of distributive justice. When quality is defined with a resource constraint dimension, at what point on an ordinal or a nominal scale of quality is inadequate care due to resource constraints not acceptable? The acceptable standard is constantly challenged from opposing directions. "Quality" becomes something of a moving target, presenting a unique set of challenges to quality assurance

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126 JO HARRIS-WEHLING programs. In particular, assessment methods and quality assurance approaches should be able to (1) identify which, and to what degree, structure, process, and outcome elements of health care are affected by the resource con- straints, (2) identify the agent or agents that are responsible for the exis- tence of the constraints and that have the authority to address the problems attributed to the constraints, and (3) carry through in some cases with cor- rective actions and monitoring for improvement in the quality of care. Examples of the resource constraint dimension are as follows: "The production of improved health . . . within the constraints of existing technology, resources and consumer circumstances."~ "The nrim~rv ~r,~1 within the r~.~,rr.ec which Its ~nc1 inclivirl~al~ ~ J&~ ~A A11~ ~ IVAN ~ . . ~ ALA ~ ~ _~V "A ~ '' AA4_~A ~V_~_ "} ~-~ A~^ ~ A~ - have chosen to spend for that care."~4 "Quality of health care . . . achieves a cost effective level in terms of both monetary and personal considerations from the patient's point of view."23 "Quality of care is a health care system that provides good care at an afford- able price to all Americans . . . with particular importance given to quality of life.~933 Some definitions may deliberately exclude a specific dimension or assert its irrelevance or inappropriateness for quality of care: "Quality of care is understood to be the highest scientific care available bal- anced by the quality of life the patient desires and needs. It should be reflec- tive of the patient's value system, and independent of utilization review and resource allocation."37 Standards of Care Palmer and Adams (1988, p. 42) stated that "quality of health care is measured by comparing data describing care received by patients to stan- dards." According to Donabedian (1988), in measuring quality our concepts of quality must be translated to concrete representations (i.e., criteria and standards of structure, process, and outcome) that are capable of some de- gree of quantification. The standards are generally based on the judgment or the practice of health care professionals. Examples supporting this dimension as a component of defining quality are as follows: "Quality patient care is that practice in any given situation which is thought by knowledgeable clinicians to be in consonance with those practices of the pertinent professional community . . . "28 "Quality care should be consistent with . . . generally accepted professional standards.',48

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DEFINING QUALITY OF CARE 129 professional knowledge. As discussed in Chapter 1 of Volume I of this report, this definition has the following properties: it in~.lil~l~.~ ~ m~cilrP Of Or~1P ~, ^~ ~^ -~ \,- e degree to which . . .); it encompasses a wide range of elements of care (. . Health ser vices . . A; it identifies both individuals and populations as proper targets for quality assurance efforts; it is goal-oriented (. . . increase . . . desired health outcomes . . A; it recognizes a stochastic (random or probability) attribute of outcome but values the expected net benefit (. . . increase the likelihood of . . .~; it underscores the importance of outcomes and links the process of health care with outcomes (health services . . . increase . . . outcomes); it highlights the importance of individual patients' and society's pref erences and values and implies that those have been elicited (or acknowl edged) and taken into acnn'~nt in h~.nith Harp. rlPriciOn melding anal Eli_ cymaking (. . . desired health outcomes . . . ); and ~^ ~^V^~^- --~s-At ~-& ~OVAL it underscores the constraints placed on professional performance by the state of technical, medical, and scientific knowledge, implies that that state is dynamic, and implies that the health care provider is responsible for using the best knowledge base available (. . . consistent with current profes- sional knowledge). In this definition, the care provided is expected to have a net benefit (to do more good than harm, given the known risk when compared to the next best alternative care). In turn, that benefit is expected to reflect considera- tions of patient satisfaction and well-being, broad health status or quality- of-life measures, and the processes of patient-provider interaction and deci- sion making. The values of both individuals and society are explicitly to be considered in the goal-setting process. How care is provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, organizational, and management elements of health care. CONCLUDING REMARKS One purpose of a quality assurance system is to achieve the proper bal- ance among the dimensions reflected in a given definition of quality, be- cause, as this analysis has demonstrated, dimensions of quality may well contradict each other. For example, dimensions of financial constraints and accessibility within a single definition may create opposing pressures on health care providers or policymakers. The committee's definition does not explicitly incorporate all the dimen- sions reflected in the quality definitions offered by other parties (Table

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130 JO HARRIS-WEHLING 5.1~. However, as discussed in Volume I, operaiionalizing the committee's definition (i.e., turning it into practical measurement and intervention ap- proaches) and implementing a quality assurance program based on it will require attention to many of these other dimensions. For example, process of care is reflected in dimensions such as technical competence, interper- sonal skills, and coordination; these dimensions cannot be neglected in quality review and assurance because they are aspects of health care that can affect the likelihood of desired outcomes. This compilation and analysis documents the richness and variety of existing definitions of quality of care, and the study committee found this analysis helpful in clarifying the bases for its own definition. This "empiri- cal evidence" significantly contradicts the often-stated view that quality cannot be defined and, thus, cannot be assessed. The committee's defini- tion (and its respective dimensions) provided guidance to the committee in designing the strategy for quality assurance as set forth in Volume I. REFERENCES Donabedian, A, The Quality of Care. How Can It Be Assessed? Journal of the American Medical Association 260:1743-1748, 1988. OTA (Office of Technology Assessment). The Quality of Medical Care: Informa- tionfor Consumers. OTA-H-386. Washington, D.C.: U.S. Government Print- ing Office, 1988. Palmer, R.H., and Adams, M.E. Considerations in Defining Quality in Health Care. Paper prepared for the Institute of Medicine Study to Design a Strategy for Quality Review and Assurance in Medicare, 1988. Steffen, G.E. Quality Medical Care. A Definition. Journal of the American Medi- cal Association 260:5 6-61, 198 8 . APPENDIX EXAMPLES AND SOURCES OF DEFINITIONS OF QUALITY* 1. High quality care means caring for and about the quality of life of each of He persons we treat. This includes attending to their physical disease, physiological events, and the medical events they experience, but also tran scends these and ultimately may be independent of the physical events or outcomes. High quality care deals with the physical, emotional, mental and *In many examples herein, the author has excerpted the phrases from material submitted to the study. An attempt has been made to retain the actual words used for defining quality but to eliminate extraneous words from the submitted texts. This approach resulted in a number of illustrative phrases rather than complete sentences.

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DEFINING QUME OF Cam 131 spiritual or meaningfulness dimensions of life, and tries to help the patient integrate all of these areas. Hattwick, M.M., Woodburn Internal Medicine Associates, Annandale, Va. Provided to study at site visit. 2. The degree of adherence to generally recognized contemporary stan- dards of clinical practice and achievement of anticipated outcome for a particular service, procedure, diagnosis, or clinical problem. St. Luke's Episcopal Hospital, Houston, Tex. Provided to study at site visit. 3. A well-trained, competent, and experienced physician plus a patient who has confidence in his or her physician. Provided to study at site visit. 4. Quality health care for the elderly is primarily that of helping the elderly individual maintain an independent existence for as long as he or she can. West Georgia Medical Center (Liz Watson), LaGrange, Ga. Provided to study at site visit. 5. Level of excellence produced and documented in the process of diagno- sis and therapy, based on the best knowledge derived from science and the humanities, and which eventuates in the least morbidity and mortality in the population. Ochsner Foundation Hospital, New Orleans, La. with acknowledgement to B.C. Payne, M.D.' formerly with the Joint Commission on Accreditation of Healthcare Organizations. Provided to study at site visit. 6. The performance of specific activities in a manner that either increases or at least prevents the deterioration in health status that would have oc- cu~Ted as a function of a disease or condition. Employing this definition, quality of care consists of two components: (1) the selection of the right activity or task or combination of activities, and (2) the performance of those activities in a manner that produces the best outcome. Brook, R.H. and Kosecoff, J.B. Commentary. Competition and Quality. Health Affairs 7:150-161, Summer 1988. 7. The degree to which patient care services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes, given the current state of knowledge. Joint Commission on Accreditation of Healthcare Organizations, 1990 Ac- creditation Manual for Hospitals, 1989.

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132 JO HARRIS-WEHLING 8. The highest quality medical care is that care that best achieves legiti- mate medical and nonmedical goals. Steffen, G.E. Quality Medical Care. A Definition. Journal of the Ameri- can Medical Association 260:56 61, 1988. 9. Quality of medical care is the capacity of that care to achieve the health care goals that are determined by the preferences and values of those pa- tients and populations who receive it. Quality therefore depends on pro- cesses necessary to establish personal and societal goals as well as the pro- ficiency with which medical knowledge and technology are applied. Mulley, A.G., Jr. Correspondence to study, 1989. 10. The perspective of the three parties . . ., providers, governments and patients, can be combined to define quality of care as the production of improved health and satisfaction of a population within the constraints of existing technology, resources and consumer circumstances. Palmer, R.H. and Adams, M.E. Considerations in Defining Quality in Health Care. Paper prepared for the Institute of Medicine Study to Design a Strat- egy for Quality Review and Assurance in Medicare, 1988. 11. 1. Good medical care is limited to the practice of rational medicine based on the medical sciences. 2. Good medical care emphasizes prevention. 3. Good medical care requires intelligent cooperation between the lay public and the practitioner of scientific medicine. 4. Good medical care treats the individual as a whole. 5. Good medical care maintains a close and continuing personal rela- tionship between physician and patient. 6. Good medical care is coordinated with social welfare work. 7. Good medical care coordinates all types of medical services. 8. Good medical care implies the application of all the necessary services of modern, scientific medicine to the needs of all the people. Lee, R.I. and Jones, W.L. The Fundamentals of Good Medical Care. Pp. ~10. Chicago, Ill.: University of Chicago Press, 1933. 12. Criteria for quality of medical care: (1) the extent to which it is avail- able, acceptable, comprehensive and documented; and (2) the degree to which adequate therapy is based on an accurate diagnosis and not sympto- matology. Esselstyn, C.B. Principles of Physician Remuneration. Paper presented at American Labor Health Association National Conference on Labor Health Services, Washington, D.C., June 1~17, 1958.

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DEFINING QUALITY OF CARE 133 13. Quality pediatric medical care embodies a scientific approach to health supervision; the establishment of a diagnosis of deviation from optimum health; institution of appropriate therapy; and management designed to sat- isfy the overall needs of the patient. It should be readily available, effi- ciently rendered and properly documented. Preventive care should be util- ized to assure optimal physical, intellectual and emotional growth and de- velopment. Osborne, C.E. and Thompson, H.C. Criteria for Evaluation of Ambulatory Child Health Care by Chart Audit: Development and Testing of a Method- ology. Final report of the Joint Committee on Quality Assurance of Ambu- latory Health Care for Children and Youth. Pediatrics Supplement 56:625-692, 1975. 14. The primary goal of a quality assurance system should be to make health care more effective in bettering the health status and satisfaction of a population, within the resources which society and individuals have chosen to spend for that care. Institute of Medicine. Advancing the Quality of Health Care. A Policy Statement. Washington, D.C.: National Academy of Sciences, 1974. 15. Essential Criteria for Hospital Care: 1. Objective substantiation of diagnosis or documentation of co-morbidity. 2. Scientifically validated therapy provided (medical) and/or indications for operative intervention met (surgical). 3. Contraindicated treatments avoided (medical) and/or lowest feasible in- cidence of preventable complications. Sanazaro, P.J. and Worth, R.M. Concurrent Quality Assurance in Hospital Care. New England Journal of Medicine 298:1171-1177, 1978. 16. Quality of care is 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. Explorations in Quality Assessment and Monitoring. Vol. I. The Definition of Quality and Approaches to its Assessment. Ann Arbor, Mich.: Health Administration Press, 1980. 17. Quality of care = f (technical care + art of care + technical and art . . ~ Interactions Lohr, K.N. and Brook, R.H. Quality Assurance in Medicine: Experience in the Public Sector. R-3193-HHS. Santa Monica, Calif.: The RAND Corpo- ration, 1984.

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134 JO HARRIS-W~HLING 18. Quality of care is the delivery of health care services in such a fashion as to most efficiently, effectively, and humanely return the patient to or maintain the patient at his highest level of functioning. American Health Care Association. Testimony submitted to study. 19. Extent to which the health services delivered satisfy the reasonable expectations of both providers and patients without either over- or un- der-utilization of resources. American Academy of Otolaryngology. Testimony submitted to study. 20. Quality of health care generally refers to the value of health care services available, selected, delivered and the resultant patient outcome that ensues. American Academy of Physical Medicine and Rehabilitation. Testimony submitted to study. 21. Quality care should produce optimal improvement in physiological status, physical function, emotional and intellectual performance and com- fort at the earliest time possible. American Board of Medical Specialties. Testimony submitted to study. 22. For the diabetic patient quality care might be defined as a compassion- ate and reasonable balance between the resources available and the need of the patient, with the responsibility of achieving quality dependent on the provider's skills and the time taken to deliver fully the tools (both cognitive and motivational) by which the consumer affects the necessary actions. American Diabetes Association. Testimony submitted to study. 23. Quality of health care encompasses the concept of appropriateness with a satisfactory outcome and achieves a cost effective level in terms of both monetary and personal consideration from the patient's point of view. American Gastroenterological Association. Testimony submitted to study. 24. Quality health care (in a hospital) is care provided in the appropriate setting, which results in patient outcomes that are optimal in arresting dis- ease or restoring function within the current limitations of medical science. American Health Care Institute. Testimony submitted to study. 25. Quality health care should be defined as the selection of the best therapeutic option, be it medical, surgical, psychosocial or environmental for an individual patient based on assessment of clinical history and physi

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DEFINING QUALITY OF CARE 135 cat examination, laboratory and imaging results, the technological resources available, the natural history of the disease process itself, and informed patient consent. Arkansas Foundation for Medical Care. Testimony submitted to study. 26. Quality is a variety and intensity of humane treatment modalities likely to cure, ameliorate or arrest an adverse medical condition with acceptable risk to the patient and at an acceptable cost. California Medical Association. Testimony submitted to study. 27. Encompass adequate means for providing access of the sick to medical care and then a high level of skill in providing up-to-date diagnostic and therapeutic measures. Center for Study of Drug Development, Tufts University. Testimony sub- mitted to study. 28. Quality patient care is that practice in any given situation which is thought by knowledgeable clinicians to be in consonance with those prac- tices of the pertinent professional community (a standard defined by the pertinent professional community); which is associated with high probabil- ity for good clinical results or outcome (standard supported by professional literature); which is consistent with policies, guidance or general require- ments of authorized accrediting bodies (a standard in consonance with legal authority); which is perceived by patient and his/her personal community to be caring, competent and effective (a standard supportive of patient dignity, understanding and outcome). Department of Defense, Office of Assistant Secretary for Health Affairs. Testimony submitted to study. 29. Quality is the best technical rendition of the best options selected for a specific patient with the patient's consent, delivered with the utmost com- passion and respect. Federation of American Health Systems. Testimony submitted to study. 30. Quality healthcare is the provision of exactly the right measure of service to restore the patient to the level of well-being he/she is capable of . . ac sieving. Health Data Institute, Baxter. Testimony submitted to study. 31. Quality of health care means the degree to which medical services are rendered in a manner that is timely, appropriate to the medical condition

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136 JO HARRIS-WEHLING and social needs of the patient, compassionate, and with consideration of the patient's finances and daily living needs. Kentucky Medical Association. Testimony submitted to study. 32. Care that is medically appropriate that fulfills the needs of the pa- tient. MassPRO (Massachusetts Peer Review Organization, Inc.~. Testimony sub- mitted to study. 33. Quality of care is a health care system that provides good care at an affordable price to all Americans (with particular importance given to qual- ity of life). National Association of Retired Federal Employees. Testimony submitted to study. 34. Maintaining or enhancing the social and psychological well-being of patients and families and promoting conditions in the environment which are conducive to this. Quality health care meets psychosocial needs. National Association of Social Workers. Testimony submitted to study. 35. High quality care is first, care that is desired by an informed patient; second, care that is based on the application of the sound judgment of the appropriate professionals involved, applied to the specific individual con- cerns and needs of the patient; and third, care that is agreed upon and carried out in a relationship of mutual trust and respect. National Institute on Aging, National Institutes of Health. Testimony sub- mitted to study. 36. As provided by hospitals and physicians only - The quality of medical care is the degree to which the process of care increases the probability of outcomes desired by patients and reduces the probability of undesired out- comes, given the state of medical knowledge. Office of Technology Assessment, Congress of the United States. Testi- mony submitted to study. 37. Quality of care is understood to be the highest scientific care available balanced by the quality of life the patient desires and needs. It should be reflective of patient's value system, and independent of utilization review and resource allocation. Providence Hospital, Anchorage, Alaska. Testimony submitted to study.

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DEFINING QUALITY OF CARE 137 38. Quality management consists of the pursuit of a standard of excellence in care by effective management of the process of care directed toward the highest level of clinical outcomes that are both desirable and feasible within the constraints of available resources. Sisters of Mercy Health System. Testimony submitted to study. 39. Quality of health care reflects judgments about the degree of excellence inherent in a specified unit of health service delivered to an individual or group of individuals. University of Washington School of Nursing. Testimony submitted to study. 40. Parameters: Quality of health care includes appropriate biomedical interventions, considers the health and care of the whole individual and emphasizes the importance of the social context of health care delivery. American Academy of Home Care Physicians. study. Testimony submitted to 41. Parameters: A definition of quality . . . must address . . . whether care is available; whether care is needed; whether outcomes are acceptable; and whether patients are satisfied. A potential fifth dimension of quality is the cost-effectiveness of care. American Hospital Association. Testimony submitted to study. 42. Parameters: The AMA has identified eight essential elements that char- acterize care of high quality. The care should: 1) produce the optimal possible improvement in the patient's physiologic status, physical function, emotional and intellectual performance and comfort at the earliest time possible consistent with the best interests of the patient; 2) emphasize the promotion of health and the prevention of disease or disability and the early detection and treatment of such conditions; 3) be provided in a timely man- ner, without either undue delay in initiation of care, inappropriate curtail- ment or discontinuity, or unnecessary prolongation of such care; 4) seek to achieve the informed cooperation and participation of the patient in the care process and in decisions concerning that process; 5) be based on accepted principles of medical science and the proficient use of appropriate techno- logical and professional resources; 6) be provided with sensitivity to the stress and anxiety that illness can generate, and with concern for the patient's overall welfare; 7) make efficient use of the technology and other health system resources needed to achieve the desired treatment goal; and 8) be sufficiently documented in the patient's medical record to enable continuity of care and peer evaluation. American Medical Association. Testimony submitted to study.

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138 JO HARRIS-WEHLItIG 43. Parameters: Benefits derived and outcomes attained for the consumer; perceptions of quality of consumers, practitioner, and accrediting organiza- tions; observable and measurable indicators American Nurses Association' Inc. Testimony submitted to study. 44. Parameters: Quality is a function of clinical outcome plus appropriate process plus patient satisfaction plus credentialing plus utilization manage- ment plus service plus risk management plus . . . Health Care Purchasers Association. Testimony submitted to study. 45. Parameters: Level of scope of available benefits; human 'scaring" as pects. International Union, United Auto Workers. Testimony submitted to study. 46. Parameters: Quality health care should consist of comprehensive, ap- propriate, medical, diagnostic, therapeutic, and preventive services deliv- ered by and/or under the supervision of a concerned physician and support staff in a timely manner; such services should be documented and provided with continuity, follow-up, outreach; and with minimal risk of making the patient worse; these services should be easily accessible to all patients with- out barriers of any type. National Medical Association. Testimony submitted to study. 47. Parameters: Quality of care is partly a function of the need for care. Includes patient's satisfaction which is a function of degree to which their service expectations are met. National Multiple Sclerosis Society. Testimony submitted to study. 48. Parameters: Quality care should be consistent with scientific knowl- edge and generally accepted professional standards. Need to pay attention to satisfaction and quality of life in addition to morbidity and mortality. National Rural Health Association. Testimony submitted to study. 49. Parameters: Concept of quality must take into account the perspectives of the following: 1) providers - concerned whether care conforms to stan- dards; 2) consumers - concerned with interpersonal skills of provider, symp- tom relief and functional improvement; 3) buyers - concerned with cost effectiveness. Pharmaceutical Manufacturers Association. Testimony submitted to study. 50. Parameters: All attempts to define and evaluate quality will fail until all care and services are provided and based on the patient's values and

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DEFINING QUME OF Cam 139 goals. Must-also incorporate essential role of informal care givers and family. Do not care for the elderly; care about them as individuals. Wellspring Gerontological Services, Evergreen Park, Ill. Testimony sub- mitted to study. 51. Parameters: a) process; b) outcome; c) physician-patient interaction; d) psycho-social, functional -and economic realities; and e) involvement of patient in decision-making. Windermere Senior Health Center, Chicago, Ill. Testimony submitted to study. 52. Achieving quality means the continuous improvement of services to meet the needs and expectations of the patients, the physicians, the payers, the employees, and the communities we serve. Hospital Corporation of America. Provided to study at site visit.