Quality Management

The Aspects of Quality Management

Donald M. Berwick identifies quality management as having three primary aspects: (a) knowing what works,(b) using what works, and (c) doing well what works. To this list, a fourth element should be added: knowing the resources needed for what works. Quality assurance and quality improvement emphasize the second and third aspects of quality management.

The resources needed to create quality are reflected in the operational structures of health care organizations, especially physical facilities and personnel requirements. The earliest quality assurance procedures employed professional or organizational measures of structure in developing licensure, certification, and accreditation for individuals, health care institutions, and educational programs. Contemporary evidence indicates, however, that structure is not highly related to process or outcomes measures of quality, providing a necessary but not a sufficient condition for quality care.

Knowing what works requires information on the efficacy of specific technologies, pharmaceuticals, and clinical interventions under controlled conditions and on the effectiveness of medical treatments and surgical procedures as well as diagnostic, preventive, and rehabilitative care in the course of practice (outcomes research). Both approaches provide evidenced-based knowledge of the impact of technical interventions or processes on the health outcomes of a segment of the population. Because of its greater use of experimental controls, efficacy studies produce results that have clearer causal implications but are less generalizable to a cohort of patients who have or might contract a disease. Effectiveness studies have become an important source of knowledge regarding the effects of medical interventions on patient mortality, morbidity, perceived health status (health-related quality of life), and satisfaction with care. For example, a study of the medical outcomes for patients experiencing low back pain when treated, respectively, by surgeons, chiropractors, or physical therapists demonstrated little difference in overall results. The study did, however, produce a storm of controversy among the professional groups.

Specific outcome indicators and benchmarked standards for them are used by accreditation groups such as the National Committee for Quality Assurance or the Joint Commission on the Accreditation of Healthcare Organizations as well as federal agencies such as the Center for Medicare and Medicaid Services and private entities such as Oregon's Foundation for Accountability.

Using what works requires health care managers to consider the appropriateness of care provided, that is, its underuse, overuse, or misuse. The term underuse refers to the omission of services that could benefit the patient, overuse to the implementation of a service that has no or a harmful result, and misuse to the improper or incorrect use of a beneficial service. Appropriateness is generally identified in two ways. First, one may assess whether the risks of doing a clinical or preventive process outweigh the benefits for a specific class of patients. Second, a process of care may be compared with a standard of care established through efficacy or effectiveness research or through a consensus among experts in the field. The results of such investigations are practice guidelines or protocols that organize knowledge for providers. The acceptance of these guidelines by providers, however, depends on a variety of factors, including provider education, feedback on their practice, incentives, peer and leader opinions, patient education, and the involvement of providers in the guideline development process.

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