Defining quality and quality improvement

Within the NHS the introduction of a statutory duty of quality in 1999 followed by clinical governance, national standards and regulatory frameworks have represented major steps towards delivering good quality healthcare. Most recently, government policy has shifted its focus away from targets and activity towards patient experience and outcomes. Lord Darzi’s High quality care for all and the ‘quality and productivity’ agenda are initiatives that have sought to embed quality at the heart of NHS healthcare delivery. 1 , 2 The recent government white paper Equity and excellence: liberating the NHS emphasises the importance of outcomes and a commitment to producing quality standards. 3 These are to be defined through an NHS outcomes framework. In order to deliver and manage quality, it is necessary to measure it, which demands a conceptual framework within which to understand the term. 4

Quality

Quality is a concept that describes those features of a product or service to which value is ascribed. Consequently, the nature of quality varies between products and services, individuals and organisations. Here it is discussed in relation to its significance within healthcare. Quality does not incorporate any idea of relative cost. Although it may be used in conjunction with cost, allowing consideration of value, the implementation of quality should not be seen as a cost-cutting exercise.

Given the subjective nature of quality, defining ‘high quality’ healthcare provision is challenging. It is not surprising that various healthcare organisations differ in their interpretations and consequently have defined it in different ways.5 The Institute of Medicine (IoM) sees 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’.6 However, in order to define quality by the development of expectations or standards, it is necessary to ascribe dimensions of quality, also known as domains.7

Different organisations opt for various numbers and combinations of these domains. In the report Crossing the quality chasm the IoM expanded on its previous statement, listing six fundamental domains of quality: safety, patient experience, effectiveness, efficiency, equity and timeliness.8 In his Next Stage Review, Lord Darzi called for high quality care for all that is ‘personal, effective and safe’.1 The US Quality Assurance Project goes further, defining nine domains of quality: access, technical performance, effectiveness, efficiency, interpersonal relationships, continuity, safety, choice, and physical infrastructure and comfort.9 The Royal College of Physicians (RCP) has adopted a definition of quality which comprises patient experience, safety, effectiveness, efficiency, equity, timeliness and sustainability (Box 1).

Box 1.

Despite the apparent variability in the number and nature of the domains ascribed, certain areas seem consistently important. A document released in March 2006 by the Organisation for Economic Co-operation and Development aimed to draw together domains of quality from the frameworks of six member countries and three international health organisations. Effectiveness, safety, patient experience, efficiency, equity and accessibility were the most frequently incorporated.10

It is of note, though perhaps not surprising, that many of the domains of quality, particularly those most frequently used, can be easily mapped onto the established four principles of medical ethics: autonomy, justice, beneficence and non-malfeasance.11 Thus, in many respects, the delivery of quality healthcare not only has ethical implications, but potentially constitutes a moral imperative.

In the evolving social, economic and political contexts of healthcare delivery, certain domains may be considered more pertinent at certain times. Interactions between different domains are inevitable and, while some of these will be synergistic, attempts to fulfil all of them may lead to tensions developing, especially in a resource-limited environment. The relationship between the domains of patient experience and equity is a ready example. Where tensions exist, the outcome that maximises quality should be sought. It may be necessary to make decisions regarding the relative importance of certain domains.