Outcomes Assessment and
What is Quality?
What exactly is quality? When
we think of quality, many images are created in our minds. Quality products
and services are perceived as being better, brighter, faster, more reliable,
and usually more costly than those of lesser quality. Some maintain qualtiy
should be free or have minimum costs since the lack of quality increases
costs in the long run. At one time, quality was viewed as a responsibility
for only the industrial and manufacturing settings. Today service
industries are now beginning to see the importance of quality.
The term quality has several definitions.
A general definition is any of the features that make something what it
is; characteristics; attributes. It has also been defined as the degree
of excellence a thing possesses; excellence, superiority. When related
to goods or services, quality takes on still more definitions. Here are
some definitions of quality related to goods or services:
- measure of how close a good or
service conforms to specified standards
- conformance to requirements
- degree to which a product or services
satisfies the wants of a specific consumer
- degree to which a specific product
or service is preferred over competing product of equivalent grade, based
on comparative tests by consumers
The issue of quality and the patient
in health care is a sensitive one. Regardless of how we define quality
or who defines quality, the patient perceives quality in the context of
their own experience.
Goal of Quality
The goal of quality is to achieve
superior external and internal customer satisfaction. The fundamental precepts
of quality are the same for all industries:
- Quality excellence can be achieved
by preventing problems.
- All work done by employees, suppliers,
and providers is part of a process that creates a product or service for
a customer. Each person can influence part of the process which affect
quality of output and eventually customer satisfaction.
- Sustained quality excellence requires
- Each employee is a customer for
work done by other employees or suppliers or providers, with a right to
expect good work from others and an obligation to contribute work of high
caliber to othes who are their customers.
- Quality is defined by the customer
who wants products and services that meet their needs and expectations
at a cost that represents value.
- People provide the intelligence
and generate the actions that are necessary to realize all improvements.
- Quality is not absolute.
Quality means different things in different situations. It cannot be measured
upon a quantifiable scale in the same way as physical properties.
- Quality is multidimensional.
Many factors contribute to quality which are not easily summarized in a
simple, quantitative way. The most easily measured criteria may not
necessarily be the most important criteria of quality.
- Quality is subject to constraints.
Assessment of quality cannot be separated from cost. Cost, in this case,
does not necessarily mean. Cost can mean people, tools, time, and other
- Quality is about acceptable
compromises. Where quality is constrained, compromises are required.
Some sacrifices may be more acceptable than others.
- Quality criteria are not independent.
Criteria which establish quality may interact with each other causing conflicts.
For example, a longer waiting time at a clinic may mean patients can get
appointments in a shorter amount of time.
- Acceptable quality changes over
time. Progress in health care is constantly raising the level of quality.
This results in an increase in actual capability and also public expectation.
of Quality in Health Care
For years the health care industry
viewed quality health care from the quality assurance angle. Quality assurance
evaluates the performance of health care providers against an established
standard of care after the care has been provided. Quality assurance is
usually characterized as a pass-fail type of assessment. Health care
providers would usually wait until a problem presented itself before an
attempt was made to solve it.
The concept of quality improvement
began to take root in the 1980's. Quality improvement seeks to evaluate
and improve overall health care performance through a structure of continual
evaluation and feedback. It emphasizes the role of the internal staff in
identifying the best practices in their respective endeavors. Quality improvement
promotes a culture which constantly seeks to optimize performance. The
focus is on elevating the performance of all health care providers to continuously
improve the system to an optimum level where superior outcomes are attained
following health care. Quality improvement attempts to identify and solve
problems before they occur. Two models of quality improvement are Total
Quality Management (TQM) and Continuous Quality Improvement (CQI).
Total Quality Management
(TQM) & Continuous Quality Improvement (CQI)
Both TQM and CQI have been used
interchangeably. Total Quality Management is defined as a strategic, integrated
management system, which involves all managers and employees and uses quantitative
methods to continuously improve an organization's processes to meet and
exceed customer needs, wants, and expectations. TOTAL implies at
every level in the organization, each and every day, in every department
and support group. QUALITY indicate continuous improvement to meet
and/or exceed internal or external customer requirements and expectations.
MANAGEMENT occurs by establishing systems and environments that
support a continuous improvement culture.
The founder of the quality movement
is W. Edward Deming, a statistician and industrial expert credited
with bringing his principles of TQM to Japan following World War II to
help the country rebuild and excel in international competition. After
WWII, American companies focused on production volume rather than quality
and did not readily accept Deming's TQM principles. The loss of the market
share experienced by the United States in the 1980's due to high-quality
imports from Japan triggered a revival to TQM in this country. Rising
costs in health care created a surge of bad publicity which in turn caused
patient dissatisfaction and an upsurge of episodes of poor quality in health
care being reported by the media. In 1988, the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) mandated a push toward TQM for guidance
and improvement in health care. This would help patients realize
what quality in health care they would be able to expect from the health
care community. Throughout the 1990's, the JCAHO quality initiative
evolved into its current performance improvement standards. For more information,
click on JCAHO.
There are several reasons why the
health care industry is showing an interest in TQM. There is a desire to
improve patient care while trying to control costs and compete for health
care consumers. Also, the public is demanding quantifiable measures of
health care quality and explanations for sources and implicatins of variations
in the level of care. Approximately 71% of hospitals engage in quality
improvement efforts as well as quality assurance programs.
to Implement TQM
- CUSTOMER FOCUS: The
customer must be identified and their needs understood. Customer requirements
must be established and some type of compliance must be in place. There
must be a partnering relationship between the customer and provider.
- TOTAL INVOLVEMENT:
Management must demonstrate commitment and leadership through real opportunities
for quality improvement for all employees. Management must delegate and
empower employees to improve their work environment through the creation
of multidisciplinary, cross-functional, self-directed teams.
- MEASUREMENT: Management
must establish a baseline measure with customers and develop the appropriate
process and result measure. These are developed by identifying the proper
input and output criteria so a relationship of congruence is established
between the customer (patient) requirements and process.
- SYSTEMATIC SUPPORT:
Management is responsible for managing the quality process. A quality
internal operating structure needs to be built which is linked to the internal
management structure. Quality performance within the organization cannot
be separated from management.
- CONTINUOUS IMPROVEMENT:
All work must be viewed as a process. Management needs to anticipate
changes as well as the needs, wants, and expectations of the customers,
employees, and society. Changes can be incremental or drastic, depending
on the need for improvement.
to Implemeneting TQM
- Assess the readiness and climate
of the organization. The organization must be ready for TQM. Various
methods to assess readiness are self-assessment, employee surveys, interviews,
and audits. The assessment is intended to supply more information
about the internal organization, management styles, level of commitment,
and receptiveness to change. This knowledge will let you know in
advance where problems exist or may occur and thus allow time to plan for
- Management must openly communicate
and daily demonstrate to all employees its commitment to TQM. Failure
to communicate can cause a decline in morale. If true commitment is not
present, everyone will do things their own way which may lead to poor service.
- Education and training of TQM
principles are continuing processes.
- Develop a strategic plan
- Energize the organization with
quality awareness. Create a management team to define the role of quality
and the organization's expectations of quality (meetings, slogans, missions,
- Change the culture of the organization.
Create a positive environment that reflects quality and customer focus.
Employees must be trained in problem-solving techniques and team philosophy.
Training must focus on the following: (1) building trust; (2) reducing
fear of the unkown; (3) creating concern for quality through personal ownership
and empowermenet; (4) providing positive communication; (5) breaking down
inter- and intradepartmental barriers; (6) uncovering problems, issues,
and concerns; (7) being open-minded; (8) soliciting, rather than waiting
for input; (9) providing timely feedback; (10) trating employees with personal
and professiona respect; (11) actively soliciting ways to improve quality;
(12) fostering employee initiative, ingenuity, and creativity; and (13)
empowering employees with true authority and responsibility for their own
- Define the scope of your commitment
to the organization as a whole. This is the most difficult step
in implementing TQM. The following must be considered: (1) customer orientation
- satisfying internal and external customers by meeting their needs, wants,
and expectations; and (2) quality goals - criteria for achieving quality.
- Identify the key process and
product of service variables. This step measures and analyzes the process
in the previous step. Provide a plan for the following: (1) Definition
- define the outputs to be measured; (2) Evaluation - gather and study
information about the process and services; (3) Validate - validate information
from evaluation with the requirements of the customer; and (4) Organization
- once a valid list of requirements is identified, the plan can be developed,
organized, and systematized. Identifying the process and product
requires a high level of interaction between managers and employees who
will be defining tasks.
- Implement statistical process
control. This step measures the quality performance of people, instruments,
methods, measurements, and environments. Key characteristics fundamental
to the design of the process are customers, management, industry standards,
government regulations, and courts.
- Incorporate process improvement
activities in the organization. Keep raising the standards. View all
standards as the minimum acceptance of quality and your organization needs
to rise above these minimum standards. High standards will make you
stand out in a crowd. Be prepared to climb the next mountain. Take calculated
risks without the fear of retaliation, name calling, or discipline of some
kind. Keep your eyes off of the competition. Move on to develop
your own niches of quality, specifications, price, and the like. Defy conventional
wisdom. Be ready to attempt new ideas and think of the benefits to the
patients. Stay on track by knowing your business. Do not compromise, continue
until improvements are made. Check your assumptions. Be willing to change.
Just because something worked yesterday does not mean it will work
today. Because of change, review and challenge your assumptions. Be open
about what you do - share with your colleagues.
- Assess the quality improvement
in the organization. Continually monitor services.
What Limits the Success
- TQM is viewed by many as a management
- Lack of commitment by management,
lack of leadership by management.
- Employees not properly trained
in TQM strategies.
Outcomes assessment is the assessment
or research which attempts to link either structure and/or process to the
outcomes of health care at the community, system, institution, or patient
Structure involves the setting in
which health care takes place. This includes the system, provider,
and patient characteristics. System characteristics include organizational
structure, mixes of health care specialties, work load, and access and
convenience issues. Provider characteristics include specialty training,
preferences, and job satisfaction. Patient characteristics include diagnosis/condition,
severity of condition or illness, and health habits.
Process involves the set of activities,
both technical and interpersonal, that occur within and between patients
and health care providers. Technical aspects include visits, medications,
referrals, test ordering, and hospitalizations. Interpersonal aspects include
communication and counseling.
The outcomes are consequences to
the health and welfare of individuals and society which include clinical
endpoints, health-related quality of life, and satisfaction with care.
Clinical endpoints involve symptoms and signs, laboratory values, and death.
Health-related quality of life includes physical, mental, and social aspects.
Satisfaction with care addresses the issues of access, convenience, and
Why do we need health outcomes information?
- To eliminate poor and/or unnecesary
practice and promote good practice.
- To aid negotiations between patients
- To increase the accountability
of services after they are delivered.
- To develop a means to evaluate
services for the chronically ill.
- To empower consumers and involve
them in service evaluation and planning.
- To evaluate new services
- To provide information for setting
priorities and allocating resources.
- To help set, monitor, and improve
standards of care.
Return to Syllabus
Stamatis, D.H. (1996). Total
Quality Management in Health Care. Irwin Professional Publishing.
Gillies, A. (1997). Improving
the Quality of Patient Care. John Wiley & Sons.
Hilborne, L.H., Leape, L.L., Paradis,
J.J., Peterson, P., & Johns, C. (1996). Quality Outcomes in an Age
of Uncertainty. Laboratory Medicine, 27:11, 731.
Yablonsky, T. (1995). Total
Quality Management in the Laboratory. Laboratory Medicine, 26:4,