National Academies Press: OpenBook

Preparing for the 21st Century: Focusing on Quality in a Changing Health Care System (1997)

Chapter: 2. Measuring the Quality of Care is Necessary to Promote Improvements

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Suggested Citation:"2. Measuring the Quality of Care is Necessary to Promote Improvements." National Academy of Sciences, National Academy of Engineering, and Institute of Medicine. 1997. Preparing for the 21st Century: Focusing on Quality in a Changing Health Care System. Washington, DC: The National Academies Press. doi: 10.17226/9538.
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standard for medical and all other records related to health care.

  • Ensure that health-database organizations take responsibility for maintaining data quality, particularly by taking steps to evaluate the completeness and accuracy of the data in the databases for which they are responsible, as well as the validity of data for the analytic purposes for which they are used.

  • Enact legislation to establish the confidentiality of person-identifiable data as an attribute of data elements themselves, regardless of who holds the data.

  • Amend the Employee Retirement Income Security Act of 1974 (ERISA), through provisions analogous to those contained in the Americans with Disabilities Act, so as to regulate employer access to individual medical information collected in connection with employment-based health benefits.

Measuring the Quality of Care is Necessary to Promote Improvements

Tested approaches already exist for measuring variations in the quality of some types of care. For more than 25 years, experts have been working to create reliable, valid ways to

Nursing Homes and Health Care Quality

Many Americans will one day have to enter nursing homes. What is the quality of care in those nursing homes? Are the horror stories that are occasionally reported accurate depictions of common occurrences? Will increasing the quality of their care make them unaffordable through Medicare and Medicaid?

Despite recent improvements in nursing-home quality and regulatory compliance, the quality of care provided by some nursing facilities leaves much to be desired. Frequently cited problems include inadequate care plans, unsanitary and hazardous environments, and unsanitary food. There is also a failure to maintain the dignity of and respect for patients. Although the use of restraints (which decrease muscle tone and increase the likelihood of falls, incontinence, ulcers, depression, confusion, and mental deterioration) has been decreased, a number of facilities still fail to recognize and promote the independence of residents.

Many residents of nursing homes have serious disabilities and problems that need skilled nursing care. Although a licensed nurse (LN) must be on duty 24 hours per day, current regulations require a registered nurse (RN) to be on duty only 8 hours per day. Nurse assistants constitute 70–90% of the nursing staff in nursing facilities. They provide most of the direct care and spend the most time with residents, but they are the least trained. Yet, in 1993, 48% of all nursing-facility residents were chairbound, and 5% were bedfast; 37% had some severe irreversible psychiatric condition (such as Alzheimer’s disease), and another 33% were receiving psychoactive medication for such conditions. This situation indicates the need for careful reviews to determine whether quality of care is adequate.

Greater RN presence on all shifts should lead to higher rates of patient survival, improved ability of residents to function independently, fewer hospitalizations, and earlier discharge from nursing homes. The additional cost of boosting RN coverage from 8 to 24 hours per day might be reduced by the potential long-term savings from better-quality health care.

For more information:

  • Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?, Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, 1996

assess the quality of care of a wide range of inpatient and outpatient services given for a broad array of health and medical problems. For some health care fields, well-understood measurement tools can be put to immediate, wide-spread use; in others, the science of quality measurement is relatively elementary, making the validity of comparative assessments suspect.

Good ways also exist for improving the quality of health care. In addition to what we know about measuring high- and low-quality care, systems and management research (involving such fields as organizational behavior, statistics, psychology, and learning) can be used to evaluate the outcome of health care decisions and thus influence favorably the institutions and people that provide health services. Organization-wide quality-improvement efforts are beginning to be adopted in the service sectors around the world. Much remains to be learned about linking these concepts and tools, most of which are not yet familiar to clinicians or health administrators, to other, better-known disciplines and approaches in health, such as technology assessment, practice guidelines, clinical evaluation, and medical decision making, as well as to the databases and

Suggested Citation:"2. Measuring the Quality of Care is Necessary to Promote Improvements." National Academy of Sciences, National Academy of Engineering, and Institute of Medicine. 1997. Preparing for the 21st Century: Focusing on Quality in a Changing Health Care System. Washington, DC: The National Academies Press. doi: 10.17226/9538.
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networks needed to incorporate them into day-to-day operations.

Overall, tools for measuring and improving health care must confront three broad kinds of quality-of-care concerns:

  1. Use of unnecessary or inappropriate care. Examples include the excessive or unnecessary use of x-ray and other diagnostic tests, unnecessary hysterectomies and open-heart surgery, and overprescription of antibiotics and some mood-altering drugs. Those practices make patients vulnerable to harmful side effects. They also waste money and resources that could be put to more productive use.

  2. Underuse of needed, effective, and appropriate care. People do not get proper preventive, diagnostic, or therapeutic services if they lack health insurance and if they delay seeking care or receive no care at all. Even those with insurance often face geographic, cultural, organizational, or other barriers that limit their abilities to seek or receive care.

  3. Shortcomings in technical and interpersonal aspects of care. Inferior care results when health care professionals lack full mastery of their clinical-practice fields, do not adequately explain key aspects of care, or cannot communicate effectively with their patients. Cases in point include preventable drug interactions and surgical mishaps, failure to monitor or follow up abnormal laboratory-test results, neglect of appropriate education and information for patients, lack of adequate coordination of care, and insensitivity to ethnic and cultural characteristics of patients. (A-1, A-2)

For more information on measuring the quality of care:

  • A-1. America’s Health in Transition: Protecting and Improving Quality, A Statement of the Council of the Institute of Medicine, 1994

  • A-2. Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicare, 1990

Accountability for Quality of Care Under Medicare Should Be Strengthened

What is Medicare’s responsibility for quality of care?

The quality-assurance strategy of the Medicare program (the

Can Quality of Care Be Defined?

Quality of care can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. That definition, formulated by a committee to design a quality strategy for the Medicare program, has been widely accepted and has proved to be a powerful tool in the formulation of practical approaches to quality assessment and improvement.

Several ideas in the definition deserve elaboration. The term health services refers to a wide array of services that affect health, including those for physical and mental illnesses. Furthermore, the definition applies to many types of health care practitioners (physicians, nurses, dentists, therapists, and various other health professionals) and to all settings of care (from hospitals and nursing homes to physicians’ offices, community sites, and even private homes).

Including both populations and individuals draws attention to the different perspectives that need to be addressed. On the one hand, we are concerned with the quality of care that individual plans and clinicians deliver. On the other hand, we must direct attention to the quality of care across the entire system. In particular, we must ask whether all parts of the population have access to needed and appropriate services and whether health status is improving.

The phrase desired health outcomes highlights the crucial link between how care is provided and its effects on health. It underscores the importance of being mindful of people’s well-being and welfare and of keeping patients and their families well informed about alternative health care interventions and their expected outcomes. Current professional knowledge emphasizes that health professionals must stay abreast of the dynamic knowledge base in their professions and take responsibility for explaining to their patients the processes and expected outcomes of care.

For more information:

  • Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicine, 1990

federal program providing health insurance to elderly people and some people with disabilities) has done much, but accountability for quality remains a concern. Medicare’s quality-assurance strategy should focus on health care

Next: 3. Accountability for Quality of Care Under Medicare Should Be Strengthened »
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