What Is Quality?

1. Defining Quality

The Institute of Medicine (IOM) has defined quality care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

In the 2001 report “Crossing the Quality Chasm,” the IOM proposed a framework that includes the following six aims for a quality healthcare system:

• Safe: Avoiding harm to patients from the care that is intended to help them
• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
• Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
• Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care
• Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy
• Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status

In other words, healthcare quality is getting the right care, to the right patient, at the right time, every time. It is interesting to note that the IOM singles out patient safety as one of their six aims, in essence, making it a subset of quality. Others may argue that patient safety is a separate entity, or that it is a discipline in its own right. Regardless of how you view it, the basic premise remains that we owe the patients we serve high-quality, safe, reliable, and effective care. Many clinicians and healthcare professionals view quality as the delivery of evidence-based care, whereas the IOM has broadened the definition to include factors that are important to patients (patient-centeredness and timeliness) as well as to society (equity). Evidence-based medicine still provides the foundation for much of quality measurement and improvement.

The Lancet Global Health Commission went further to define a high-quality health system as "one that optimizes healthcare in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs." The improvement of health outcomes is essential for health systems; these outcomes include longer lives, a better quality of life, and improved ability to function.

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2. Measuring Quality

Quality can be an elusive goal. The traditional approach to healthcare service quality has focused more on activities required to satisfy regulators and identify outliers than on continuous efforts to meet customer needs. But now, faced with increasingly sophisticated consumers making demands for quality, clinicians and providers are seeking effective ways to serve and retain patients within the realities of resource constraints.

In the last 50 years, the United States has progressed from defining quality to measuring quality, then, to publicly reporting quality measures, and more recently, to holding people accountable for outcomes.

More groups such as public and private payers, regulators, and accreditors are requiring measures that certify performance levels for consumers. Here are some benefits of quality measures:

• stimulation of new quality measures
• improved transparency to meet IOM aim and enhance accountability
• publicly reported measures associated with improved levels of quality

hint

The hospital core measure program has shown increased evidence-based care across the country.

The number of quality measures that healthcare providers are required to report has skyrocketed over the last decade, and this trend will likely continue. Further, payers require increasingly varied systems of measurement. The number of National Quality Forum approved measures has risen from 200 measures in 2005 to 1,122 in 2020. The U.S. Centers for Medicare and Medicaid Services (CMS) recommended 82 hospital quality performance measures just for publicly reported Hospital Compare data. Many more measures exist for required inpatient quality-reporting metrics as well as value-based purchasing.

This multiplicity of quality metrics that healthcare systems are required to report has many negative consequences. To capture these metrics requires a lot of resources and forces improvement dollars to be devoted to these high-profile, publicly reported data. This leaves little in the budget to pursue more relevant goals, such as patient-centered health outcomes and healthcare-associated harm. Sometimes, to meet the metric, providers choose to take minimal measures such as merely handing out a smoking cessation brochure instead of enrolling the patient in a program and using aids such as nicotine patches to change behavior. Other less-effective actions taken can involve, for instance, hiring a heart failure nurse to improve the discharge process, thereby scoring high but adding costs without improving the reliability of the basic process. With these actions, we aren’t fixing the underlying issues and therefore we are creating a never-ending process of hitting the metric without making sustainable systems and process improvements to deliver high reliability care; this means wasting precious resources for little gain.

big idea

Performance improvement should be focused on what matters most to an organization based on where they are in their quality journey. The set of quality performance measures should be balanced to address what we need to do for patients, communities, and our country: better outcomes, better care, and lower per capita costs. The IOM framework—including the six aims—provides guidance for building the high reliability organization we strive for.

Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM

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