Definitions
The Institute of Medicine has defined quality 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” (Lohr 1990)˳ Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity˳ In practical terms, poor quality can mean too much care (e˳g˳, providing unnecessary tests, medications, and procedures, with associated risks and side effects), too little care (e˳g˳, not providing an indicated diagnostic test or a lifesaving surgical procedure), or the wrong care (e˳g˳, prescribing medicines that should not be given together, using poor surgical technique)˳
Quality can be evaluated based on structure, process, and outcomes (Donabedian 1980)˳ Structural quality evaluates health system characteristics, process quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients’ health status˳ All three dimensions can provide valuable information for measuring quality, but the published quality-of-care literature reveals that there is more experience with measuring processes of care˳ Two particular techniques, which measure a type of process quality called “technical process quality,” dominate the literature˳
Technical process quality refers to whether care is provided skillfully and whether the right choices are made in diagnosing and treating the patient˳ The latter (making the correct choices) is generally measured by assessing appropriateness or adherence to professional standards˳
An intervention or service (e˳g˳, a lab test, procedure, medication) is considered appropriate if, for individuals with particular clinical and personal characteristics, its expected health benefits (e˳g˳, increased life expectancy, pain relief, decreased anxiety, improved functional capacity) exceed its expected health risks (e˳g˳, mortality, morbidity, anxiety anticipating the intervention, pain caused by the intervention, inaccurate diagnoses) by a wide enough margin to make the intervention or service worth doing (Brook et al˳ 1986)˳ A subset of appropriate care is necessary or crucial care˳ Care is considered necessary if there is a reasonable chance of a nontrivial benefit to the patient and if it would be improper not to provide the care˳ In other words, it might be considered ethically unacceptable not to provide this care (Kahan et al˳ 1994; Laouri et al˳ 1997)˳ Appropriateness criteria and necessity criteria can be used, respectively, to measure overuse of care, which is a problem because of treatment complications and wasted resources, and underuse of care, which means that people are not getting care expected to improve their health˳
Another way to measure process quality is to determine whether care meets professional standards˳ This assessment can be done by creating a list of quality indicators that describe a process of care that should occur for a particular type of patient or clinical circumstance and then evaluating whether patients’ care is consistent with the indicators˳ Quality indicators are based on standards of care, which are either found in the research literature and in statements of professional medical organizations or determined by an expert panel˳ Current performance can be compared against a physician’s or plan’s own prior performance, against the performance of other physicians and plans, or with reference to a benchmark that establishes a goal˳ Indicators can cover a specific condition (e˳g˳, children with sickle cell disease should be prescribed daily penicillin prophylaxis from at least six months of age until at least five years of age), or they can cover general aspects of care regardless of condition (e˳g˳, patients prescribed a medication should be asked about medication allergies)˳
