Professional Documents
Culture Documents
Before assessment can begin we must decide how quality is to be defined and located in the system of care and on
that depends on whether one assesses only the performance of practitioners or what the nature and extent of our re¬
also the contributions of patients and of the health care system; on how broadly sponsibilities are. These several formu¬
health and responsibility for health are defined; on whether the maximally lations can be envisaged as a progres¬
effective or optimally effective care is sought; and on whether individual or social sion, for example, as steps in a ladder or
as successive circles surrounding the
preferences define the optimum. We also need detailed information about the bull's-eye of a target. Our power, our
causal linkages among the structural attributes of the settings in which care
occurs, the processes of care, and the outcomes of care. Specifying the
responsibility, and our vulnerability all
flow from the fact that we are the foun¬
components or outcomes of care to be sampled, formulating the appropriate dation for that ladder, the focal point for
criteria and standards, and obtaining the necessary information are the steps that family of concentric circles. We
that follow. Though we know much about assessing quality, much remains to be must begin, therefore, with the perfor¬
known. mance of physicians and other health
care practitioners.
(JAMA 1988;260:1743-1748)
As shown in Fig 1, there are two ele¬
ments in the performance of practitio¬
ners: one technical and the other
THERE time, not too long ago,
was a True, some elements in the quality of interpersonal. Technical performance
when this question could not have been care are easy to define and measure, but
depends on the knowledge and judg¬
ment used in arriving at the appropriate
asked. The quality of care was consid¬ there are also profundities that still
ered to be something of a mystery: real, elude us. We must not allow anyone to strategies of care and on skill in imple¬
capable of being perceived and appreci¬ belittle or ignore them; they are the menting those strategies. The goodness
of technical performance is judged in
ated, but not subject to measurement. secret and glory of our art. Therefore,
comparison with the best in practice.
we should avoid claiming for our capa¬
The best in practice, in its turn, has
For editorial comment see p 1759. city to assess quality either too little or earned that distinction because, on the
too much. I shall try to steer this middle
course. average, it is known or believed to
The very attempt to define and measure produce the greatest improvement in
quality seemed, then, to denature and SPECIFYING WHAT QUALITY IS health. This means that the goodness of
belittle it. Now, we may have moved too technical care is proportional to its ex¬
far in the opposite direction. Those who Level and Scope of Concern
pected ability to achieve those improve¬
have not experienced the intricacies of Before we attempt to assess the qual¬ ments in health status that the current
clinical practice demand measures that ity of care, either in general terms or in science and technology of health care
are easy, precise, and complete—as if a any particular site or situation, it is nec¬ have made possible. If the realized frac¬
sack of potatoes was being weighed. essary to come to an agreement on what tion of what is achievable is called effec¬
the elements that constitute it are. To tiveness, the quality of technical care
From the University of Michigan School of Public proceed to measurement without a firm becomes proportionate to its effective¬
Health, Ann Arbor. foundation of prior agreement on what
This article was written for the AMA Lectures in Medi-
ness (Fig 2).
cal Science: it is the basis for a lecture in that series quality consists in is to court disaster.1 Here, two points deserve emphasis.
given on Jan 11, 1988, by invitation of the Division of As we seek to define quality, we soon First, judgments on technical quality
Basic Sciences, American Medical Association, become aware of the fact that several are contingent on the best in current
Chicago.
Reprint requests to 1739 Ivywood Dr, Ann Arbor, MI formulations are both possible and knowledge and technology; they cannot
48103. legitimate, depending on where we are go beyond that limit. Second, the judg-
by Patient
<D
I
agers of the institution.
Contribution of Provider By moving to the next circle away
Contribution of Patient from the center of our metaphorical tar¬
and Family get, we include in assessments of quali¬
.„ Care Received by ty the contributions to care of the pa¬
Community tients themselves as well as of members
Access to Care Time of their families. By doing so we cross an
Performance of Provider important boundary. So far, our con¬
Performance of Patient cern was primarily with the perfor¬
and Family Fig 2.—Graphical presentation of effectiveness (in mance of the providers of care. Now, we
disease). Solid line indicates course of
a self-limiting
are concerned with judging the care as it
illness without care; dotted line, course of illness
Fig 1.—Levels at which quality may be assessed. with care to be assessed; and dashed line, course of actually was. The responsibility, now, is
illness with "best" care. Effectiveness equals shared by provider and consumer. As
A/(A + B). already described, the management of
the interpersonal process by the practi¬
tioner influences the implementation of
care by and for the patient. Yet, the
patient and family must, themselves,
ment is based on future expectations, quality of care? There are many rea¬ also carry some of the responsibility for
not on events already transpired. Even sons. Information about the interper¬ the success or failure of care. Accord¬
if the actual consequences of care in any sonal process is not easily available. For ingly, the practitioner may be judged
given instance prove to be disastrous, example, in the medical record, special blameless in some situations in which
quality must be judged as good if care, effort is needed to obtain it. Second, the the care, as implemented by the patient,
at the time it was given, conformed to criteria and standards that permit pre¬ is found to be inferior.
the practice that could have been ex¬ cise measurement of the attributes of We have one more circle to visit, an¬
pected to achieve the best results. the interpersonal process are not well other watershed to cross. Now, we are
The management ofthe interpersonal developed or have not been sufficiently concerned with care received by the
relationship is the second component in called upon to undertake the task. Part¬ community as a whole. We must now
the practitioner's performance. It is a ly, it may be because the management of judge the social distribution of levels of
vitally important element. Through the the interpersonal process must adapt to quality in the community.3 This de¬
interpersonal exchange, the patient so many variations in the preferences pends, in turn, on who has greater or
communicates information necessary and expectations of individual patients lesser access to care and who, after
for arriving at a diagnosis, as well as that general guidelines do not serve us gaining access, receives greater or
preferences necessary for selecting the sufficiently well. lesser qualities of care. Obviously, the
most appropriate methods of care. Much of what we call the art of medi¬ performance of individual practitioners
Through this exchange, the physician cine consists in almost intuitive adap¬ and health care institutions has much to
provides information about the nature tions to individual requirements in tech¬ do with this. But, the quality of care in a
of the illness and its management and nical care as well as in the management community is also influenced by many
motivates the patient to active collabo¬ of the interpersonal process. Another factors over which the providers have
ration in care. Clearly, the interper¬ element in the art of medicine is the no control, although these are factors
sonal process is the vehicle by which way, still poorly understood, in which they should try to understand and be
technical care is implemented and on practitioners process information to ar¬ concerned about.
which its success depends. Therefore, rive at a correct diagnosis and an appro¬ I have tried, so far, to show that the
the management of the interpersonal priate strategy of care.2 As our under¬ definition of quality acquires added ele¬
process is to a large degree tailored to standing of each of these areas of ments as we move outward from the
the achievement of success in technical performance improves, we can expect performance of the practitioners, to the
care. the realm of our science to expand and care received by patients, and to the
But the conduct of the interpersonal that of our art to shrink. Yet I hope that care received by communities. The defi¬
process must also meet individual and some of the mystery in practice will nition of quality also becomes narrower
social expectations and standards, always remain, since it affirms and or more expansive, depending on how
whether these aid or hamper technical celebrates the uniqueness of each narrowly or broadly we define the con¬
performance. Privacy, confidentiality, individual. cept of health and our responsibility for
informed choice, concern, empathy, The science and art of health care, as it. It makes a difference in the assess¬
honesty, tact, sensitivity—all these and they apply to both technical care and ment of our performance whether we
more are virtues that the interpersonal the management of the interpersonal see ourselves as responsible for bring¬
relationship is expected to have. process, are at the heart of the meta¬ ing about improvements only in specific
If the management of the interper¬ phorical family of concentric circles de¬ aspects of physical or physiological
sonal process is so important, why is it picted in Fig 1. Immediately surround¬ function or whether we include psycho¬
so often ignored in assessments of the ing the center we can place the logical and social function as well.
2O
O iCost will be a point beyond which additions to care can be classified under three
"¡D care will bring about improvements categories: "structure," "process," and
that are too small to be worth the added "outcome."110
cost. Now, we have a choice. We can Structure.—Structure denotes the
ignore cost and say that the highest attributes of the settings in which care
°
quality is represented by care that can occurs. This includes the attributes of
be expected to achieve the greatest im¬ material resources (such as facilities,
provement in health; this is a "maximal¬ equipment, and money), of human re¬
ist" specification of quality. Alterna¬ sources (such as the number and qualifi¬
tively, if we believe that cost is cations of personnel), and of organiza¬
important, we would say that care must tional structure (such as medical staff
A B stop short of including elements that organization, methods of peer review,
Useful Additions to Care
are disproportionately costly compared and methods of reimbursement).
with the improvements in health that Process.—Process denotes what is
they produce. This is an "optimalist" actually done in giving and receiving
Fig 3.—Hypothetical relations between health specification of quality. A graphical rep¬ care. It includes the patient's activities
benefits and cost of care as useful additions are resentation of these alternatives is in seeking care and carrying it out as
made to care. A indicates optimally effective care; shown in Fig 3. well as the practitioner's activities in
and B, maximally effective care.
Health care practitioners tend to pre¬ making a diagnosis and recommending
fer a maximalist standard because they or implementing treatment.
only have to decide whether each added Outcome.—Outcome denotes the ef¬
element of care is likely to be useful. By fects of care on the health status of
Valuation of the
contrast, the practice of optimal care patients and populations. Improve¬
Consequences of Care requires added knowledge of costs, and ments in the patient's knowledge and
Still another modification in the also some method of weighing each add¬ salutary changes in the patient's behav¬
assessment of performance depends on ed bit of expected usefulness against its ior are included under a broad definition
who is to value the improvements in corresponding cost.8 Yet, the practice of of health status, and so is the degree of
health that care is expected to produce. optimal care is traditional, legitimate, the patient's satisfaction with care.
If it is our purpose to serve the best even necessary, as long as costs and This three-part approach to quality
interest of our patients, we need to in¬ benefits are weighed j ointly by the prac¬ assessment is possible only because
form them of the alternatives available titioner and the fully informed patient. good structure increases the likelihood
to them, so they can make the choice A difficult, perhaps insoluble, problem of good process, and good process in¬
most appropriate to their preferences arises when a third party (for example, creases the likelihood of a good out¬
and circumstances. The introduction of a private insurer or a governmental come. It is necessary, therefore, to have
patient preferences, though necessary agency) specifies what the optimum established such a relationship before
to the assessment of quality, is another that defines quality is.* any particular component of structure,
source of difficulty in implementing
Preliminaries to Quality Assessment process, or outcome can be used to as¬
assessment. It that no precon¬
means sess quality. The activity of quality as¬
ceived notion of what the objectives and Before we set out to assess quality, sessment is not itself designed to estab¬
accomplishments of care should be will we will have to choose whether we will lish the presence of these relationships.
precisely fit any given patient. All we adopt a maximal or optimal specification There must be preexisting knowledge
can hope for is a reasonable approxima¬ of quality and, if the latter, whether we of the linkage between structure and
tion, one that must then be subject to shall accept what is the optimum for process, and between process and out¬
individual adjustment." each patient or what has been defined as come, before quality assessment can be
Monetary Cost as a Consideration socially optimal. Similarly, we should undertaken.
have decided (1) how health and our Knowledge about the relationship be¬
Finally, we come to the perplexing responsibility for it is to be defined, tween structure and process (or be¬
question of whether the monetary cost (2) whether the assessment is to be of tween structure and outcome) proceeds
of care should enter the definition of the performance of practitioners only or from the organizational sciences. These
quality and its assessment.1,7 In theory, also include that of patients and the sciences are still relatively young, so
it is possible to separate quality from health care system, and (3) whether the our knowledge of the effects of struc¬
inefficiency. Technical quality is judged amenities and the management of the ture is rather scanty.1112 Furthermore,
by the degree to which achievable im¬ interpersonal process are to be included what we do know suggests that the rela¬
provements in health can be expected to in addition to technical care. In a more tionship between structural character¬
be attained. Inefficiency is judged by practical vein, we need to answer cer¬ istics and the process of care is rather
the degree to which expected improve¬ tain questions: Who is being assessed? weak. From these characteristics, we
ments in health are achieved in an un¬ What are the activities being assessed? can only infer that conditions are either
necessarily costly manner. In practice, How are these activities supposed to be inimical or conducive to good care. We
lower quality and inefficiency coexist conducted? What are they meant to cannot assert that care, in fact, has been
because wasteful care is either directly accomplish? When we agree on the good or bad. Structural characteristics
harmful to health or is harmful by dis¬ answers to these questions we are ready should be a major preoccupation in sys¬
placing more useful care. to look for the measures that will give tem design; they are a rather blunt in-
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