Outcomes Assessment and Quality Assurance

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:

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:

Primary Characteristics of Quality

Historical Perspective 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.

Assumptions Required to Implement TQM

Considerations Prior to Implemeneting TQM

TQM Implementation Steps

What Limits the Success of TQM?

Outcomes Assessment

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 level.

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 quality.

Why do we need health outcomes information?

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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, 254-260.