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All cases BMZ2024Case 1 – caring for quality
Problem statement = what is quality of care?
Learning goals:
1. What is quality of care?
Ayanian, J. Z., & Markel, H. (2016). Donabedian’s Lasting Framework for Health Care Quality. New
England Journal Of Medicine, 375(3), 205-207. doi:10.1056/NEJMp1605101
IOM → 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) –
Donabedian (1990)
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
Not one definition of quality of care
Doing the right things right
Institute of Medicine (U.S.). Committee on Quality of Health Care in America. (2001). Crossing the
quality chasm : A new health system for the 21st century. Washington, D.C.: National Academy Press.
ISBN: 9780309511933
Underlying reasons for inadequate quality of care
1. Growing complexity of science and technology
2. The increase in chronic conditions
3. A poorly organized delivery system
◼ Evidence-based, planned care
◼ Reorganization of practices to meet the needs of patients who require more time, a
broad array of resources, and closer follow-up
◼ Systematic attention to patients’ needs for information and behavioral change
◼ Ready access to necessary clinical expertise
◼ Supportive information systems
4. Constraints on exploiting the revolution in information technology
5. Access to the medical knowledge-base
6. Computer-aided decision support systems
7. Collection and sharing of clinical information
8. Reduction in errors
9. Enhanced patient and clinician communication
2 main import
Obedy
First most important quality measure was patient centeredness and the second one was efficiency
,patient centredness could be subsumed
Characteristics by quality of care
Structure
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, equipment and buildings.
Campbell, S.M., Roland, M.O., Buetow, S.A., (2000). Defining quality of care. Social Science and
Medicine. 51; 11, 1611-1625
Quality definition
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, expectations or goals which have been met.
Quality 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'.
Generic definitions are not easily operationalizable and trade both sensitivity and specificity for
generalizability.
Each individual component of quality provides a partial picture of quality when viewed on its own,
but other more specificity in defining quality when viewed in combination. However, we propose
that there are only two domains of quality →
◼ Access
◼ Effectiveness.
Access
Do users get the care they need?
Whether individuals can access health structures and processes of care which they need.
- Geographic/physical like geographic barriers
- Availability with organizational access as a sub-component of availability.
➔ Organizational access if people are physically able to access a health facility, they may
still face barriers to accessing care in terms, for example the length and availability of
appointments or whether the health professionals can speak their language.
- Affordability like monetary costs
Effectiveness → Is the care effective when they get it?
Effectiveness is the extent to which care delivers its intended outcome or results in a desired process,
in response to need.
◼ Clinical care: Evidenced based, legitimate and knowledge based care. Knowledge-based
care incorporates the extent to which a treatment or service is consistent with patients'
reasonable expectations and contemporary professional standards of care, reflecting
both societal and professional norms.
◼ Inter-personal care: effective care requires appreciation of the patient’s personal
experience of illness, and must align the agendas of the professional and the patient.
, Care should be planned for and with individual patients through negotiation between
doctor and patient and shared responsibility for care.
Individual and population level
Individual → patient access to health structure and process and if the treatment is efficient
Population → equity added; people have the healthcare they need what also takes equity.
2. What frameworks of quality of care?
➔ Applying to theory of practice; try to come up with an example case or apply this to a
practical case or examples
Donabedian framework
◼ 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)
Ransom ER, Joshi MS, Nash DB, Ransom SB (2008). The healthcare quality book: vision, strategy, and
tools. Health Administration Press, Chicago; AUPHA Press, Washington, DC. Chapter 2: Basic concepts
of Healthcare Quality (P.25-40).
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) – IOM
(1990)
Definitional attributes
1. Technical performance (= how well current scientific medical knowledge and technology are
applied in a given situation)
➔ Assessed in terms of the timeliness and accuracy of the diagnosis, appropriates of
therapy, and skills with which procedures and other medical interventions are performed
2. Interpersonal relationship (= how well the clinician relates to the patient on a human level)
Important because:
➔ For the clinician’s own sake
- The clinician is able to fully address the patient’s concerns, reassure the patient, and
relieve the patient’s suffering
➔ It can affect technical performance
- The clinician is able to elicit from that patient a more complete and accurate medical
history which can result in a better diagnosis
➔ The patient can be motivated to follow a prescribed regime of care
, - o Example: medication or lifestyle changes
3. Amenities (= the characteristics of the setting in which the encounter between patient and
clinician takes place)
- Example: comfort, convenience, and privacy
- Example: ample and convenient parking, good directional signs, comfortable waiting
rooms, and tasty hospital food
➔ Important because
- Potential effect on the technical and interpersonal aspects of care • Indirect benefits
- Example: comfortable, private setting → good interpersonal relationship → more
complete patient history → faster and more accurate diagnosis
4. Access (= the degree to which individuals and groups are able to obtain needed services) ▪
- Example: the amount of the provider charges exceeds what the patient is able or
willing to pay, the provider’s location in relation to the patient’s capacity to reach it,
days and times when care is available in relation to when the patient is able to come
in for care , cultural characteristics and expectations of the patient match with those
of the provider
5. Responsiveness to patient preferences (= taking into account the wishes and preferences of
patients)
6. Equity (= the amount, type, or quality of healthcare provided can be related to the
individual’s need for care or healthcare preferences)
➔ Medicine does not fulfill its function adequately until the same perfection is within the
reach of all individuals. Health equity arises from access to the social determinants of
health, specifically from wealth, power and prestige
7. Efficiency (= how well resources are used in achieving a given result)
- Improves whenever the resources used to produce a given output are reduced
- Inefficient care uses more resources than necessary, it is wasteful care, and care that
involves waste is deficient – and therefore of lower quality – no matter how good it
may be in other respects
8. Cost-effectiveness (= determined by how much benefit, typically measured in terms of
improvement in health status, the intervention yields for a particular level of expenditure)
Different definitions
Although everyone values to some extent the attributes of quality just described, different
stakeholders tend to attach different levels of importance to individual attributes, resulting in
differences in how clinicians, patients, managers, payers and society each tend to define quality of
care.
This table (2.1) is an attempt to capture the stereotypical differences among these groups on the
basis of how much they value individual attributes of care in the context of quality.
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