“Quality is never an accident; it is always the results of intelligent efforts” John Ruskin.The Institute of Medicine defined quality as “Thedegree to which health series for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IMO, 2004)”. Quality of care was usually measured by patient satisfaction, which is mainly related to the outcomes triggered by getting the medical care within the healthcare facilities. However, the quality of healthcare is much more than a matter of patient satisfaction and technical care, it is a total sum of different components classified using a framework and special matrices or criteria.
Donabedian’s Model – Quality of Healthcare
According to Donabedian’s classification, quality can be assessed using three main components; structure, process, and outcomes (Figure 1). The structure is related to the physical environment including the facility’s building, design, technology, and equipment.
The structure is also related to the healthcare provider’s credentials and qualifications. Structure refers to the organizational factors that define the health system under which care is provided. Whereas the process refers to the way of organizing the services within the facility. The process is also related to how efficiently healthcare is provided by taking into consideration patient safety, infection control and reducing medical errors.Finally, the outcomes are assessed by improving patient health status and patient satisfaction. (Figure 2).
Moreover, the structure is represented by the physical environment including design and healthcare required inputs. This structure affects both the process component (staff safety and performance) and patient safety (infections, medical errors, and injuries). Furthermore, the structure can also affect the outcomes component represented by “effectiveness” impacting clinical outcomes and patient satisfaction.
Overuse, Underuse and Misuse of Healthcare Quality
On the other hand, poor quality of care is represented in three forms;
Overuse of unnecessary or ineffective treatment, or
Underuse which reflects the failure to provide the care that works, and
Misuse means making mistakes that enhances medical errors.
Overuse is when care provided is inappropriate, and underuse when not provided when necessary. However, both are correlated with less effectiveness of care resulted in unwanted outcomes. Whereas misuse is correlated with poor process resulting in an inefficient quality of care.
Thus, efficiency and effectiveness are two important aspects of quality. The former represents the process and the latter represents the outcomes (Figure 3). According to the Institute of Medicine, effectiveness is defined as “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 overuse)”. Efficiency is defined as “avoiding waste of equipment, supplies, ideas, and energies”.
Effectiveness is related to achieving the intended outcomes and results. In healthcare setting, effectiveness is about making sure that “the right things are done”. Whereas the efficiency is related to performance, process, using best methods without wasting. It’s about “Doing things right”
Example for Overuse, Underuse and Misuse of Healthcare Quality
Underuseis a problem since clinical research has produced many proven results. For example, beta blockers are effective in preventing heart attacks among patient who previously had a heart attack. Soumerai and his colleagues (1997) found that it was only 21% of the time the eligible elderly patients were prescribed beta blockers upon hospital discharge after their first heart attack. More recent studies suggest that the underuse of beta blockers (not only in US but also in other parts of the world) occur because hospital-and clinician based prescribing patterns.
Overuse is also quality problem, Gonzales, Steiner, and Sande (1997) document that overuse of antibiotics among their samples of adults. They found out that antibiotics were prescribed 51 % of the time of common colds. 42% of upper respiratory infections, 75% for bronchitis. The indiscriminate use of antibiotics has led to the rise of multi-drug -resistant strains of bacteria.
Misuse caught the public attention. The first IOM report on patient safety (Kohn et al.,2000), which examined the high rate of medical errors in hospitals, noting, as pointed our earlier, that thousands of patients die every year from preventive adverse events and another million are injured. In 1999, the IOM estimated that the costs to the U.S. economy totaled between $ 37.6 and $ 50 billion each year. Recent studies estimate that 3.5 % to 6% of outpatients will experience moderate to serious adverse drug events.
The box below shows quality measures collected for hospital Compare, Process of Care Measures – using timely and effective care. Outcome of Care Measures – using Readmission, complications, and deaths. Outpatient Imaging Efficiency Measures – through use of medical image.
Quality Measures Collected for Hospital Compare
Timely and Effective Care (Process of Care Measures)
Heart Attack (Acute Myocardial Infraction [AMI])
Heart Failure (HF)
Surgery (Surgical Care Improvement Project – SCIP)
Emergency Department Care
Children’s Asthma Care
Readmission, Complications, And Deaths (Outcome of Care Measures)
30-day death (mortality) rates and 30-day readmission rates