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Case 3 Quality Management in Healthcare
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Case 3: Quality Management in HealthcareLearning goals:
How is quality managed in healthcare?
1. What is quality of care?
a. Dimensions
b. Levels
2. What is quality management?
a. Quality assurance
b. Which approaches can you use?
3. Why do we have to assess quality of care?
4. How do we assess quality of care?
Literature suggestions:
Donabedian A. (2003). An Introduction to Quality Assurance in Health Care. Oxford:
Oxford University Press.
- Introduction (page xxiii-xxxii).
The Meaning of Quality Assurance
I shall define quality assurance to mean all actions taken to establish, protect, promote, and
improve the quality of health care. Strictly speaking, one cannot assure or guarantee quality.
One can only increase the probability that care will be "good" or "better." Because quality
cannot be guaranteed, many, myself included, have criticized the term assurance. Suggested
alternatives have been improvement or, better still continuous improvement, terms meant
to remind us that no given level of quality can be fully satisfactory; one should always try to
do even better, progressing to ever higher levels of goodness.
Another alternative, the term quality management, is useful in sug- gesting that the quality
of health care is subject to managerial oversight. Unfortunately, the term may also be
understood to mean that there can be several levels of quality that cost more or less and,
therefore, can be offered at correspondingly higher or lower prices.
The Targets of Quality Assurance
By targets I mean the functions and activities that are subject to quality assurance.
Traditionally, in health care, quality assurance has been meant to apply predominantly, or
even exclusively, to health care itself as provided directly to patients by legitimate health
care practitioners.
In recent years, under the rubric of "total quality management," it has become popular to
include in the idea of quality assurance almost every function or activity of a health care
organization or system, includ- ing such things as the performance of housekeeping crews,
secretarial and clerical services, the billing and fee-collecting office, and so on.
,The Components of Quality Assurance
Quality assurance activities can be divided into two parts. One I call "system design and
resources," and the other "performance monitoring and readjustment."
- It is obvious that without resources of sufficient quantity and good quality we cannot
offer the best care we are potentially capable of. More- over, the system of care
should be designed so that it helps the delivery of good care rather than creating
obstacles to it.
- System design corresponds to what later I shall call "structure." It includes
professional recruitment, education, training, and certification. It also includes the
number, distribution, equipment, organization, and licensure of hospitals and other
health care facilities. It includes, further- more, the testing and marketing of drugs
and biologicals, the financing of care, access to health services, legal protection of
consumer and pro- vider interest, and so on.
Quality monitoring (the activity by which we keep the quality of care under constant
observation) can be thought of as the eyes and ears of the system of health care. Without it,
we do not know where we are or where we are going.
The Quality Monitoring Cycle
The main steps in the monitoring cycle are seen to be:
, 1. Obtaining data on performance.
2. Pattern analysis; an activity that is essentially epidemiological in nature.
3. Interpretation; which means advancing hypotheses that might ex- plain the patterns
observed.
4. Taking preventive, corrective, or promotive action based on the causal hypotheses
that have been advanced.
5. Obtaining data on subsequent performance to determine the con- sequences of the
actions taken.
Some Foundations of Quality Assurance Through Monitoring
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