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• Defining Quality in Health Care
Health care quality may be defined in various ways, from the differing viewpoints of health care providers, patients, third-party payers, policy makers, and other stakeholders. In terms of clinical and non-clinical health care, what is important and what is ideal will vary depending on the perspective of the stakeholder.
Another way to define quality is the result of a system with interdependent parts that must work together to achieve outcomes such as those noted above. Using this system perspective, Avedis Donabedian (1966) defined quality in terms of structure, process, and outcome. The structural elements of quality involve the material and human resources of an organization and the facility itself. The quality of personnel is documented in their numbers (nurse staffing), skill level (e.g., certified nursing assistant), and various certifications (e.g., board-certified physician), while the quality of facilities lies in accreditation (in hospitals through The Joint Commission) and/or certification (e.g., Magnet Hospital certification). Process involves the actual delivery of care as well as its management (e.g., the quality of basic care including cleanliness, feeding, hydration, delivery of treatments, and keeping patients safe from falls and errors). Outcome is the resulting health status of the patient (e.g., mortality, morbidity, length of stay, and functional status) and organizational issues (e.g., turnover of staff, cost outcomes, etc.). As a physician, Donabedian championed the development of best practices, i.e., "the ideal to which organizations should aspire" to improve care (Cooper, 2004, p. 827), linking structure, process, and outcome with a feedback loop, i.e.,information given back to providers to achieve better care. Moreover, he defined quality as having at least four components (Donabedian, 1986): The technical management of health and illness;
The management of the interpersonal relationship between the providers of care and their clients; The amenities of care; and,
The ethical principles that govern the conduct of affairs in general and the health care enterprise in particular.
The four parts of this definition highlight the need to incorporate multiple stakeholder perspectives to understand health care quality. On one hand, the technical management of health focuses on the clinical performance of health care providers; on the other hand, the management of interpersonal relationships underscores the
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