Quality Assurance

Quality assurance in health care is a broad topic that may also be referred to in a general way as continuous quality improvement, total quality management, or quality control, or by other terms. The name applied may suggest the specific type of quality model used by the institution or program. In general, quality assurance programs ensure that there are criteria for assessment and quality improvement activities that evaluate, maintain, and improve the quality of health care provided to patients.

The concept of total quality management (TQM) was developed by W. Edwards Deming, after World War II, for improving the production quality of goods and services. The concept was not taken seriously until the Japanese, who adopted it in 1950 to resurrect their postwar business and industry, used it to dominate world markets by 1980. By then most U.S. manufacturers had finally accepted that the 19th-century assembly-line factory model was not effective if they were to remain competitive in the new global economic markets.

There are many approaches to quality assurance. These approaches generally employ the principles of measurement, customer focus, and statistically based decision making. A quality assurance, or performance assessment, and continuous quality improvement includes structural criteria, process criteria, and outcome criteria as well as peer review and appropriateness evaluation.

Structural measures include board certification of physicians, licensure of facilities, compliance with safety regulations, and so on. Many of these criteria are delineated in state and local laws and regulations. Accreditation and regulatory agencies may focus on structural criteria, because such criteria may be clearly documented.

Process criteria measure the way care is provided. Process measures can include screening rates, follow-up service measures such as appointment waiting times.

Outcome criteria evaluate the outcome of the care or service. Standard outcome measures include infection rates, morbidity, and mortality. Poor outcomes generally mandate a careful review. Although structural criteria and process criteria should be linked to outcomes, unfortunately a poor outcome often offers little insight into the causes of poor performance.

Peer review involves a comparison of individual practices either by peers or by comparison to an acceptable standard of care. These standards may be developed within a local community (practice guidelines) or by national professional associations. Cases may be identified through noting when specific quality indicators are not met or through review of medical records. Managed care companies may also consider appropriateness evaluation (such as appropriateness of admission or procedure) in their quality review process.

Methods of building on the traditional quality assurance programs may be described as quality management programs. In addition to the quality assurance criteria, they include a clear aim or purpose that is not a part of a traditional quality assurance program. Organizational goals may be achieved by identifying customer (patient) needs, thereby unifying the purpose within the organization. Having this vision, customer focus becomes a cornerstone of a modern quality management program. Key customers, customer needs, and improvement processes to meet those needs are then integrated into the program. Issues identified for change and the implementation of changes are often evaluated through the “plan-do-study-act” cycle that is used as the framework for a trial-and-learning model.

...