Defining quality of care
Introduction
Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have increased interest in measuring and improving the quality of health care in many countries of the world. Quality improvement is high on the national agenda both in the UK (Roland, Holden & Campbell, 1999) and in the USA (Schuster, McGlynn & Brooks, 1998). There has been a move away from assessing costs and activity to assessing quality with an emphasis on both efficient use of resources and on the effectiveness of health care. In the UK this trend has led to an emphasis on both performance measurement and quality improvement for the NHS, and the development of a national performance framework (Department of Health, 1997, NHS Executive, 1999). Within this, clinical governance will form a framework through which ‘NHS organisations are accountable for monitoring and improving the quality of their services’, with the aim of promoting ‘an environment where excellence of clinical care will flourish’ (NHS Executive, 1998a, NHS Executive, 1998b).
The increasing focus by governments on improving quality of care requires that the concept is clearly understood. In this paper we define quality of care. We focus specifically upon care received by individuals from formal institutional health care systems which individuals or carers have chosen to access. Care in this context refers to care provided by any health care professional. We suggest that there are two dimensions of quality in this context; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? There are two key elements of effectiveness — clinical effectiveness and the effectiveness of inter-personal care — and both of these should be related to need. These elements are discussed with reference to the structure of the health care system, processes of care and outcomes resulting from care. The aim of accessing effective health care for individuals is to maximise health benefit according to need. We suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care.
However, care for individuals must be placed within the context of providing health care for populations. We also define quality of care for populations by reference to a separate but overlapping set of criteria reflecting the opportunity cost of providing care for any individual patient or group of patients. We show how our framework can be of practical value by applying the concepts outlined to the set of performance indicators proposed for use in the UK (NHS Executive, 1999) and a widely used set of US quality indicators, HEDIS 3.0 (National Committee for Quality Assurance, 1998). A framework is important as it both increases understanding of what such sets of indicators mean and also those aspects of care that should be covered and which are, and are not, actually being covered.
Many symptoms experienced by individuals are not presented to formal health care systems (Rogers, Hassell & Nicholaas, 1999). We recognise that pathways to formal care are complex and multidimensional (Campbell and Roland, 1996, Rogers et al., 1999). They are dependent on factors which include the sociodemographic characteristics of the population (Ben-Shlomo, White & McKeigue, 1992; MacIntyre, McIver & Sooman, 1993), health need (Evandrou, Falkingham, Le Grand & Winter, 1992; Feinstein, 1993) and factors such as lay support (Robinson & Granfield, 1986; Oakley, 1994), frequent attendance (Neal, Heywood, Morley, Clayden & Dowell, 1998) and health beliefs (Egan and Beaton, 1987, Murray and Corney, 1990, Van der Kar et al., 1992).
However, this paper does not focus on the attributes of health care systems which might influence consulting behaviour. Rather, we focus specifically upon care received by individuals from formal institutional health care systems starting from where an individual or carer has decided to access care. We first define the components of care, then the attributes of quality. We bring these together to provide a framework to describe quality of care.
Section snippets
Defining health care
Definitions of care are varied and contested (Heyman, 1995, Webb, 1996, McCance et al., 1997). For the purposes of this paper, we define health care as being composed of health care systems and actions taken within them designed to improve health or well-being. Donabedian, 1966, Donabedian, 1988) first proposed a systems-based framework of structure, process and outcome. These have also been described as categories of care (Ellis & Whittington, 1993). Donabedian’s model has been used previously
Defining quality
Quality has been defined in a number of different ways (Crosby, 1979, Donabedian, 1980, Maxwell, 1984, Peters, 1987, Juran, 1988). Definitions of quality are either generic or disaggregated — approaches which are not inherently incompatible but can be seen as opposite ends of a continuum. Generic definitions of quality include excellence (RCGP, 1994), expectations or goals which have been met (Ellis & Whittingham, 1993; Steffen, 1988), ‘zero defects’ (Crosby, 1979) or fitness for use (Juran,
Defining quality of care for individual patients
We propose a combined generic and disaggregated approach to defining quality of care. Our definition of quality of care for individuals is:
whether individuals can access the health structures and processes of care which they need and whether the care received is effective.
Fig. 3 shows how access and effectiveness can be related to health care structures, to processes of care, and outcomes, to produce a taxonomy of quality of care for individual patients. We now develop this argument by
Defining quality of care for populations
We have suggested that quality of care has most meaning when applied to the level of the individual user of health care. After all, it is individuals who are the recipients of care. Questions about quality of care for individuals cannot be answered by reference to populations, only put in to the context of a social construction of quality of care. Borrowing from economics we recognise that care is not given as part of a closed model ceteris paribus. For example, most economic evaluations of
Practical application of the framework
In this section, we demonstrate the utility of the framework by applying it to two sets quality indicators, the NHS National Performance Framework in the UK, and the HEDIS set developed for the assessment of health plans in the United States by the National Committee for Quality Assurance (NCQA, 1998). We show how the framework can be used to demonstrate what aspects of care are being measured and what are not, and we also show how it can be used as a framework to permit critical analysis of
Discussion
There is no universally accepted definition of care, quality or quality of care. In this paper we suggest that quality of care for individual patients is defined by their ability to access effective care with the aim of maximising health benefit in relation to need. This is not to say that other dimensions of quality identified previously in Fig. 2 are not important, but that their role in delivering quality of care for individuals is dependent upon users actually getting the care they need and
Acknowledgements
The authors would like to thank Peter Bower, Toby Gosden and Ruth Young for helpful comments on earlier drafts of this paper.
References (98)
- et al.
Accounts of disagreements with doctors
Soc. Sci. Med.
(1998) - et al.
Cost-effectiveness/utility analyses. Do current decision rules lead us to where we want to be?
J. Hlth Econ.
(1992) - et al.
Compassionate–emphatic physicians: personality traits and social–organisational factors that enhance or inhibit this behaviour pattern
Soc. Sci. Med.
(1996) - et al.
Response to symptoms in healthy, low utilizers of the health care system
J. Psychosom. Res.
(1987) Inequalities in health and health service use: evidence from the General Household Survey
Soc. Sci. Med.
(1991)- et al.
Confusion of levels in monitoring outcomes and/or process
The Lancet
(1996) - et al.
Caring: dealing with a concept
Int. J. Nurs. Stud.
(1997) - et al.
From quality assurance to quality improvement. The Joint Commission on Accreditation of Healthcare Organizations and Emergency Care
Emerg. Med. Clin. N. Am.
(1992) - et al.
The frequent consulter in primary medical care
J. Psychosom. Res.
(1986) - et al.
Measuring quality in healthcare: what lessons can the UK learn from the US?
Lancet
(1998)
Is primary care essential?
Lancet
Quality of care: A comparison of preferences between medical specialities and patients with chronic diseases
Soc. Sci. Med.
Quality judgements by patients on general practice care: A literature analysis
Soc. Sci. Med.
Process and outcomes in general practice consultations: Problems in defining high quality care
Soc. Sci. Med.
The household context for womens’ health care decisions: Impacts of UK policy changes
Soc. Sci. Med.
Collaborative overview of randomised trials of antiplatelet therapy. 1: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients
Br. Med. J.
The doctor, his patient, and the illness
Prediction of general practice workload from census based social deprivation scores
J. Epid. Community Hlth
Health, personal mobility, and the use of health services in rural Norfolk
J. Rural Studies
Taking equity seriously: a dilemma for government from allocating resources to primary care groups
Br. Med. J.
The significance of socio-economic factors in health for medical care and the National Health Service
Quality of care — what is it?
N. Engl. J. Med.
The RAND/UCLA Appropriateness Method
Managed care is not the problem, quality is
JAMA
Measuring quality of care
N. Engl. J. Med.
Four strategies for negotiated care
J. R. Soc. Med.
Why do people consult the doctor? Factors influencing demand for primary medical care
Family Pract.
Hard-earned lives. Accounts of health and illness from East London
Rural general practice
Br. J. Gen. Pract.
Opportunity costs on trial: New options for encouraging implementation of results from economic evaluations
Quality is free — The art of making quality certain
Assessing the quality of care
Br. Med. J.
Evaluating the quality of medical care
Milbank Q.
Explorations in quality assessment and monitoring. Volume 1: The definition of quality and approaches to its assessment
The quality of care: How can it be assessed?
JAMA
The seven pillars of quality
Arch. Pathol. Lab. Med.
Quality assurance in health care: a consumers’ role
Qual. Hlth Care
Quality, cost, and health: An integrative model
Med. Care
Quality assurance in health care — A handbook
Equity in health and social care
J. Soc. Pol.
The relationship between socio-economic status and health: A review of the literature
Milbank Q.
What future for continuity of care in general practice?
Br. Med. J.
Measuring quality with routine data: avoiding confusion between performance indicators and health outcomes
Br. Med. J.
League tables and their limitations: Statistical issues in comparisons of institutional performance
J. R. Statist. Soc. Series A
Quality of care: 1. What is quality and how can it be measured?
Can. Med. Assoc. J.
Cited by (834)
Accessibility and availability of reproductive health care services at primary health centre level and association with health outcome in Aspirational Districts of India
2023, Clinical Epidemiology and Global HealthCare coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study
2023, International Journal of Nursing StudiesDoes prospective payment influence quality of care? A systematic review of the literature
2023, Social Science and MedicineUsing blockchain oracle for data management: A case study on health insurance network
2024, Asia-Pacific Journal of Science and Technology