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.

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 continuous improvement.
• 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 resources.
• 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.

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).

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.

• 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.

• 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 appropriate resolution.
• 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, values).
• 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 work environment.
• 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.

• TQM is viewed by many as a management approach.
• 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 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?

• To eliminate poor and/or unnecesary practice and promote good practice.
• To aid negotiations between patients and providers.
• 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.

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References:

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.