Perceptual Gaps in Services Quality

Health care quality is ultimately in the eye of the beholder. The concept of quality in health care has continued to advance and change as providers, consumers, regulatory agencies, and payer groups have maintained their [Page 419]interest in the topic, but it is the understanding of quality from the customer perspective that is currently emerging as a critical issue in health services delivery. And, for various reasons, consumers are not satisfied with the quality being offered.

In the 1980s, health care quality became a blend of clinical, profession, and consumer input, with the consumer perspective becoming the dominant perspective. Consequently, providers began trying to manage customer perceptions and used marketing strategies to accomplish that task. Since that time, providers have evaluated, reported, and marketed positive results such as patient satisfaction levels, managed care satisfaction, intentions to use a provider again in the future, Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) survey results, compliance with advice and treatment regimens, turnover of staff, malpractice lawsuits' results, health care outcomes, and National Committee for Quality Assurance (NCQA) reports. All this work is directed toward demonstrating that the quality for a particular health care provider exceeds the competition and, in fact, does provide quality health care services. This effort seeks to eliminate the perception of gaps in one organization and to cast doubt regarding quality on another organization.

Another significant factor in perpetuating the concept of gaps in health care quality is the constant bombardment of the American public with negative reports and publicity issued by the media regarding clinical disasters and outcomes by health care providers. One need only listen to television or read the news occasionally to be made aware of poor outcomes of care provided. An investigative report by the Chicago Tribune stated that more than 100,000 deaths in the year 2000 were linked to infections that patients contracted in the nation's hospitals. The report indicated that most of the deaths were preventable and that nosocomial infections (those acquired in hospitals) represented the fourth leading cause of mortality among Americans, behind heart disease, cancer, and strokes. Another significant finding is that tens of thousands of those infections resulted from doctors and nurses failing to wash their hands.

The Institute of Medicine (IOM) issued a startling report in 1999, “The Urgent Need to Improve Health Care Quality.” That investigation and report concluded that the quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine and that serious and widespread problems exist throughout U.S. medicine. The problems could be classified as underuse, overuse, or misuse and occur in small and large communities alike. The report also proposed that the problems occur with equal frequency between managed care and fee-for-service systems of care, with the effect that very large numbers of Americans are harmed in the process. In fact, the report indicated that U.S. hospitals were responsible for between 45,000 and 98,000 deaths each year. This is equivalent to one 747 airliner crashing every other day. The report called for massive reforms and improved reporting systems.

...