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Samenvatting IMPROVING QUALITY OF CARE
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CasesCase 1; Caring for quality
Learning goals:
1. What is quality of care?
Quality of care (= the degree to which health services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current professional knowledge)
Explain the 6 domains included in the case (safety, timeliness, effectiveness, efficiency, equity and patient-
centeredness)
Crossing the Quality Chasm (report 2001): quality as six dimensions
- Safety
o Causing no harm by care that is intended to help. Reliable, standardized care will reduce
error, resulting in safer health care systems.
o Patients should not be harmed by the care that is intended to help them, nor should harm
come to those work in health care.
- Timeliness
o Reducing unnecessary waiting or delay within the health care system, such as waiting for
surgery.
o Behavior of nurses, came when called, came back when they said they would…
o Behavior of care providers: Keeping appointments and giving time and attention
- Effectiveness
o Matching science to care, this dimension is closely linked to the adoption in western health
care of evidence-based medicine.
o Effectiveness refers to care that is based on the use of systematically acquired evidence to
determine whether an intervention, such as a preventive service, diagnostic test, or therapy,
produces better outcomes than alternatives including the alternative of doing nothing.
o Evidence-based practice is the integration of best research evidence with clinical expertise
and patient values.
o Avoiding underuse or overuse
- Efficiency
o Care that is not wasteful in terms of duplication of effort and unnecessary treatment, but also
includes making full use of all resources, such as enabling staff to be innovative.
o Resources are used to get the best value for the money spent
▪ Reduce quality waste
▪ Reduce administrative or production costs
- Equity
o Closing the gap between justice and health care, in which care should not be influenced by
individuals’ personal characteristics.
o Subcategory: access
o The goal of a health care system is to improve health status and to do so in a manner that
reduces health disparities among particular subgroups
o Equity in care implies universal access
- Patient centeredness
o Care that is respectful of an individual’s preferences, needs and values and incorporates the
notion of ‘nothing about me without me’ (IOM, 2001)
o Gerteis et al. 1993 several dimensions of patient-centered care
▪ Respect for patients’ value, preferences and expressed needs
▪ Coordination and integration of care
▪ Information, communication, and education
▪ Physical comfort
▪ Emotional support
▪ Involvement of family and friends.
- Accessible: the degree to which individuals and groups can obtain needed services (time, money)
, - Acceptability
STEEEP
Which of the 6 domains are the most important?
- It is not easy to choose which one is the most important
- Patient-centeredness leads to better effectiveness of system, patient in charge can express their needs,
what treatment they expect and deem to be the most important
Michelle Beattie , Ashley Shepherd , & Brian Howieson. (n.d.). Do the Institute of Medicine’s (IOM’s)
dimensions of quality capture the current meaning of quality in health care? – An integrative review.
Journal of Research in Nursing, Vol. 18.
- Clinicians: focus on outcomes/
performance
- Patients: interpersonal aspects of care,
are my preferences taken into
account
- Payers: quality in context of costs
- Managers: non-clinical aspects like
access to care and cost-
effectiveness
- Society: integrated view of all
aspects
Many definitions exist depending on the focus
or perspective
The IOM is a non-profit organization which aims to provide government and private industries with non-
biased information about healthcare.
John Z. Ayanian , & Howard Markel. (n.d.). Donabedian’s Lasting Framework for Health Care Quality.
New England Journal of Medicine, Vol. 375. https://doi.org/10.1056/NEJMp1605101
2. What does the model of Donabedian consist of and how can we use these components
to improve quality of care? (Apply to at least one real life example)
Donabedian’s (2005) three components approach for evaluating the quality of care underpins
measurement for improvement. The three components are structure, process and outcomes
, Outcome measures: these reflect the impact on the patient and demonstrate the end result of your
improvement work and whether it has ultimately achieved the aim(s) set.
Process measures: these reflect the way your systems and processes work to deliver the desired
outcome.
Structure measures: these reflect the attributes of the service/provider such as staff to patient ratios
and operating times of the service. These are otherwise known as input measures.
According to Donabedian, outcome measures remain the ‘ultimate validators’ of the effectiveness
and quality of healthcare but can sometimes be difficult to define and have time lags.
Process measures are important in quality improvement as they describe whether or not clinical care
has been ‘properly applied’ or if we are ‘doing the things we say we should do’. From an
improvement perspective, they make the important connection between behavioural changes and
outcomes.
He defined “structure” as the settings, qualifications of providers, and administrative systems
through which care takes place; “process” as the components of care delivered; and “outcome” as
recovery, restoration of function, and survival. These concepts remain the foundation of quality
assessment today.
- Structure: the settings, qualifications of providers and administrative systems through which care
takes place
- Process: the components of care delivered
- Outcome: recovery, restoration of function and survival
, Structure → settings, qualifications of providers, and administrative systems through which care takes place
- Education, training, and certification of professionals who provide care and the adequacy of the
facility’s staffing equipment, and overall organization
- Physical and staff (teamwork)
Process → the components of care delivered
- Appropriateness (right actions were taken)
- Skill (how well actions were carried out and how timely they were)
Outcome → recovery, restoration of function, and survival
- Include the costs of care as well as patients’ satisfactions with care
Structure refers to the organisational factors that define the health system under which care is provided
(Donabedian, 1980). We identify two domains of structure: physical characteristics and staff characteristics,
and Fig. 1 shows the dimensions of each of these domains. Components of the dimension of resources
include, for example, personnel (personeel), equipment and buildings.
Processes of care involve interactions between users and the health care structure; in essence, what is done
to or with users. Process is the actual delivery and receipt of care. Two key processes of care have often
been identified: technical interventions and inter-personal interactions between users and members of a
healthcare system.
- Technical care refers to the application of clinical medicine to a personal health problem
(Donabedian, 1980) and is based upon a theory of function which can be evaluated for efficacy and
generally standardised. Care should be appropriate and necessary (Kahan et al., 1994, Brook, 1994).
In practice, care is often overused, i.e. provided when inappropriate, and underused, i.e. not provided
when necessary (Brook et al., 1996, Schuster et al., 1998). Both necessary and appropriate care must
be seen from both ends of the scale; for example, appropriateness is used as much to define what is
inappropriate as appropriate. We suggest that clinical care is the more appropriate term to use as
there are also technical aspects to inter-personal care, e.g. specific skills in relation to giving
information to patients. We therefore define the process of care in terms of clinical and interpersonal
aspects of care.
- Interpersonal care describes the interaction of health care professionals and users or their carers. This
includes “the management of the social and psychological interaction between client and
practitioner” (Donabedian, 1980). A number of skills underlie good inter-personal skills including:
communication, the ability to build a relationship of trust, understanding and empathy with the
patient (Blumenthal, 1996) and to show humanism, sensitivity and responsiveness (Carmel & Glick,
1996). Patients want explanation and discussion about their symptoms (Woloshynowych, Valori &
Salmon, 1998), and to be involved in decisions about their management.
Outcomes are consequences of care. Structure as well as processes may influence outcome, indirectly or
directly. For example, a patient may die from cervical cancer either because a screening service is not
available (structure) or because her cytology report is misread (process). However, the relative importance
of each of these components will vary in different situations and the relationships between them are not
necessarily linear.
Our framework focuses upon care for individual users so outcome in Fig. 1 refers to health status and user
evaluation, e.g. satisfaction, enablement (Howie, Heaney & Maxwell, 1996) and health related quality of
life. These must also be related to patient expectations and to the needs of that individual patient (Stott et al.,
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