What do we mean by quality?

No one speaks of health care at the moment without talking about quality – better quality, quality measures, pay for performance, quality metrics, publication of quality data, accreditation – the list goes on and on.  But, what do we mean by quality?

It is my observation that we are running into problems in the discussion of quality because, although we use the same word, frequently we are talking about discordant ideas.  These differences arise depending one’s place and role in the health care system.

Doctors typically think of quality in terms of “best” and “best outcome”.   It’s quite simply the way they are trained.  They have a historical view, supported by tort law, that their only responsibility is to the patient in front of them.  Consequently, they focus on best investigation and best treatments, both because they believe it is the right thing to do, and because of increasing fears of litigation.  More worrisome is that doctors have little system literacy because their academic medical education didn’t address it.  They have little to no knowledge of cost, and have no mechanisms to understand value.  Their assumption that all medical activity is of the same value is simply incorrect.

Quality, when used by system managers and politicians almost universally references cost.  The next time you hear one of them use the word quality, substitute the word “cost” and see if it fits.  It almost always will.  Quality in this context has become a polite proxy for “cheaper”.  It’s naturally so – it can’t really be in the interest of the funder or manager to look at long term outcomes when the 5, 10, 15 or 20 year outcomes are outside of the standard measurement patterns, funding cycles, and political cycles.

Quality, when used by patients can mean something totally different.  Patients pay attention to the amount of time they have with their doctor or nurse.  They want good communication.  They want their provider to be is interested in their problem.  Importance is given to the testing and diagnostic regimen.  Patients want their care to be up to date.

From this, it’s easy to see that the people can sit at a table and talk about quality and really be talking about entire different ideas with very different implications.  I like the approach of Health Quality Ontario which acknowledges the multiple facets of  quality –  that care is accessible, effective, safe, patient centred, efficient, adequately resourced, integrated, focused on population health, and equitable.  We need to consider all of these when we are making decisions – and increasingly we have to address equity in a system where the funding resource cannot address all of the needs.  I don’t have an answer – I won’t be presumptuous to think I have the answer, but I hope we can quickly agree on what we are going to talk about when we speak of quality.

The comments section is closed.

  • Jana says:

    Public opinion?
    Or Public consultation with flatter hierarchy and sober fact based input with those who have experience and knowledge about their community needs, what works, systems function, family and organizational/cultural function and resource management, from the integrated and non-integrated points of view and willingness to understand the long term, iterative -growth nature of such undertakings?

    If you are referring to the USA NIH report / endorsed “the Oregon Project” that is part of the child poverty reduction program and a populist citizens initiative within the USA then I also must inform with a few additional stats.

    A related 2009 OECD study generally agreed, placing the U.S. 24th out of 30 OECD countries for children’s health and safety. It also showed the **devastating effects of inequality*** in our country.
    ***Despite having the second-highest average income for children among the 30 OECD countries****, the U.S. ranked 27th out of 30 for child poverty (percentage of children living in households that are below 50% of the median income).
    (Common Dreams..2012…)
    So if you want the American Dream . . .go to Norway.

    How does one measure relative change of the Oregon Project with such disparity? How does one measure similarities and differences in such vastly different systems with such (hopefully) vastly different ‘VALUE’s?

  • Andrew Holt says:

    Hello Mark
    I can’t help but suggest that in the end it is far more effective to make the inherent structures of our parliamentary democracy work versus adding yet another agency (diluting accountability, adding overhead costs). Why not refine, refocus, properly fund, empower … or whatever else it takes the LHIN’s so they can achieve their original mandate? Wouldn’t this be less disruptive, cost less, have a higher probability of success and open the possibility for actually achieving a more integrated approach for health and social services that actually meet the health care needs and values across Ontario?

    How do we inject some of the challenges outlined by the anonymous Tapoff blogger into the LHINs in a constructive and productive way? It would be interesting to hear if Tapoff has something further to say about this.

    • Mark MacLeod says:

      Ideally it would be best to use current structures to accomplish needs. Giving the LHINS the money and power to purchase services from providers and institutions in a competetive market place would be a good first step. I do think medicine is a business, a very serious business and using all of the skills of business to buy best value make sense when the resource is scarce. We are currently using a very strange set of market deforming forces to contort medicine where normal supply/demand/wage/price balalnces don’t work. Medicine right now seems more like a cottage industry where we don’t really know what it costs to make something, we make up the price, we make decisions without sound plan or policy etc.

      Could the LHINS do it – of course. Any structure could likely do it. It really comes down to a matter of culture which is a matter of people. If the structure changed but the same old people with the same old perspectives/lack of skills, vision, or capacity end up in the new structure – voila! – plus ca change (no italics or accents available)

      My biggest concern with allowing the LHINS to do it without overriding agency is simply what happens to politics you move down the food chain. Someone commented that a new agency would have politics involved and no better off – ever seen how vicious the politics are at the municipal level and how big the distortions are when powerful local players get invovled? I’m not sure that LHINS alone can do the change piece that is required.

      At the end of the day I pretty much despair for a solution. I think there are far too many silent spectators standing on the sidelines wanting or hoping for the current system to fail – doctors, patients, commercial enterprises, institutions, politiciians alike – all who see freedom or opportunity on the other side of a failed health care system. We will know in 10 years.

  • Jana Keller says:

    Mark MacLeod, Have you described this Authorized Health Services Agency system and its mandate?
    From what models are you drawing?
    Do you really “believe” there will not be constraint driven politics external and internal?
    Do you really “believe” there will not be bureaucratic power struggles, especially if there are arbitrary and rigid hierarchical decision making structures?
    What “outcomes” would there be and how would the iterations of “quality” change? “Quality” and its measurement is a continuously iterative process. It involve the people and processes from the entire system and culture.
    How does that consideration enter into your structure?

    • Mark Macleod says:

      Well here are a few thoughts.

      In terms of structure – what about a combination of the best attributes of the Bank of Canada and the operations of the National Health Service?

      Mandate – to determine the health services that will be provided and the quantity of those services. The agency would negotiate the amount of money with government that would be available to finance the agency’s work and that in turn would dictate the services available. The agency would determine the services based on a value mandate.

      Of course there will be power struggles, but I don’t see those struggles which occur at the Bank of Canada causing significant changes in the financial policy of the country or the value of the dollar. Why should they in health? Why must they in health?

      The agency would do it’s work with the public primarily – see the Oregon project – and use public opinion to inform the decision making process.

  • Andrew Holt says:

    In theory I see your point.
    In practice I question the ability of governments, the public, special interest groups and the media to actually agree to become sufficiently politically disengage to allow for the formation and success of such a dispassionate body. Doesn’t this bring us full circle and start to sound like the role of professional public service bureaucrats working on behalf of the elected governments in a democracy?

    What can we learn from the initial experience of decentralizing much of the day to day functioning of the Ministry of Health to Local Health Integration Networks (LHIN) and the various preceding Boards, Agencies and Health Councils.

    • Mark Macleod says:

      Andrew – yes I suppose it does however I think the dispassionate, non political bureaucracy died at the Ministry of Health with the Rae government. I think now the bureaucracy always is subject to the whims of politicians. Hence projects like the Wait Times project which was overtly political in design. If the bureaucracy is to be “that body”, it will have to become completely divorced from the political arm. At this time, I don’t think it’s possible.

      In terms of the success of decentralization and the success of LHINS, my own opinion is that the LHINS were, at least in part, set up to defray criticism and at the same time were given insufficient resources to actually do what they were asked to do. I think that the LHINS are finally getting rolling now and are meeting with some success at coordinating care.

    • TapOff says:

      Although political disengagement may not be possible, the effectiveness of the system may be better gained (not gamed) by the people who actually use and work in it. The people it serves, Patients and those needing “pre” and “post” “medical” care….i.e., Health Care and the associated social services. Many of us have been a patient at one time or another. Some of us may have been cared for a little better than others for one reason or another. Geography, knowledge, navigability, luck, ….perhaps association?

      Lowering hierarchies and re-rationalizing the systems according to equitable need rather than arbitrary unrepresented manufactured emergencies by the “Political/economic” is getting very old.

      The original model is a National **comprehensive** single payer HEALTH CARE plan. We still do not have that 50 years on. Health and well being is NOT a business.
      We *do* have the advantage of many computers **full** of very good (and not so good ) national and international data and summaries of that data. Much of that data are synthesized and disseminated amongst many good minds who are eager to help make a difference and build better, functional models in Canada using progressive ideas.
      These data tells us what works and what does not work so well. This is true in health Care and in Organizational structure Behaviour and its “leadership” and management, and even economically/functionally.
      It is not simply about assessing the structure. The **CULTURE** that got us here, should be assessed by ALL who are using the system(s). Some really innovative actions have occurred across Canada. I have not read of any of them even mentioned on this BLOG. I challenge people to look hard for them. Then at them. then examine them in the context of *different*, *flatter*, interactive, hierarchical structures.
      Making a **different** but **same old** — **same old** bureaucracy does not cut it.
      Community input is required to establish equity in access and appropriate care models is an important part of a re-design.
      The resource management and how all the moving parts function together successfully and not so successfully need to be assessed by all players (sort of a stack of “work breakdown schedules”) and their associated problem solving sessions…..
      Knowledge experts exist along the entire continuum of these processes.
      We need to draw from Many non-medical systems and structural and organizational behavioural models to establish extremely well functioning integrated systems for highly responsive, evidence based (or what some name “outcome”)producing, flexible, “quality”, and even, in the true sense of the word, “benchmarked” effectiveness.
      Then and only then will the actual Health needs (acute and National Well Being– (or Cruder —determinants of health for those older people) be met in all communities. Access will then be more equitable and services be more rational.
      Who knows?! these systems may even, provide relatively greater quality of life, greater scores on well being incidences and overall prosperity for Canada.
      We need to make such socially relevant problems really democratic.
      Demos after-all is theGreek word for…. Population…..(not politician).

      • Andrew Holt says:

        Dear Tapoff
        Thank you for engaging in this discussion and challenging us all to re-conceptualize health care from the perspective of the patients, using the latest technologies, evidence and reconsider how we can better organize our collective efforts to make health services more accessible based upon the health care needs and with an over riding concern for equity. I applaud your candor and seeking of a better way forward.

        A few areas you may want to explore further include: the differences between raw ‘data’, knowledge and it’s practical application to health care at a large scale. The ‘old’ adage’ of garbage in = garbage out is true even when packaged on a colorful pictograph or is instantly transmitted anywhere in the world and trumpeted as ‘ground breaking new evidence.’ Critical appraisal pioneers in the 70’s and 80’s which spawned the move to ‘evidence-based’ medicine in the 1990’s where intellectual giants whose work continues to teach lessons today for those with the humility to learn. Getting back to first principles would be a useful exercise for the health system to undergo as the health sector re-conceptualizes based on the significant breakthroughs of the current generation.

        Values are essentially at the core of health care – for everyone – therefore it is a highly political topic for all. I suspect we would be well served to be more explicit and conversant in our collective discourse regarding the ethics of decision making as it relates to health care.

        And lastly, how we eventually decide to provide health care by building structures, systems, processes, policies, ‘objective measures of quality’ …. they always reflect how society at large balances the many competing priorities over time. If we reduce health care to a mindless series of work breakdown schedules governed by inanimate computerized decision algorithms we will have lost a huge opportunity to in fact empower individuals with knowledge and tools so they can become active participants in their own health care.

        Yes it is time to rethink health care … and build a model that rebalances decision making so it better meets the overall goals we all claim to be pursuing … truly serving patients based on their health needs.

        Thank goodness there are many people that selflessly work to keep our health care services operating today – no matter how flawed and in need to repair it may be.

  • Mark MacLeod says:

    Catherine – thanks for your comments and your personal experience.

    As you can see, the challenge is that the elements of quality are not uniformly oriented and in a system where there are limited resources all elements cannot be served at the same time for every patient. Efficiency and patient centredness might not always work together at least in the way that patients want the system to serve them. Equity and and a focus on population health might mean we abandon futile treatments that are not curative in favour of population health measures that we know make a difference. If you are the patient for who treatment is not available, population health might not mean much if you are grasping at straws.

    These are difficult choices and require thoughtful discussion with those involved – the public, providers, funders, policy makers all need input and someone, somebody needs to make sense of all of the inputs and make a decision that will not please everyone.

    • Andrew Holt says:

      If we don’t start here where does progress begin? Centering our debate clearly on the immediate trade offs for patients, their clinical advisers and the broader and longer term interests of society through our government and other representatives ultimately is necessary for progress to be made in improving our health care system. All other players are secondary but necessary contributors through the creation of new knowledge and theories (researchers), new products and services (vendors), new organizational structures (administrators, policy analysts and regulators, government bureaucrats, professional and other agencies …).

      What is the right balance between individual and societal needs for health services and the immediate versus long term perspectives? There is a critical need to create such a forum as we move into the next half century of Publicly Funded Health and Social services in Ontario and Canada.

      • Mark MacLeod says:

        Hence my idea of an agency to deliver and authorize health services. Politcians and current governance can’t/won’t do it. If we can’t count on politicians and government to speak clearly and honestly, and tell people difficult stories and make difficult decisions, where can the real work get done?

  • Catherine Richards says:

    Mark Macleod: I agree with your assessment of how we all tend to describe the meaning of quality in healthcare depending upon what role we play in the healthcare system. In particular, I agree with your description of how many patients would define quality in healthcare.

    As a patient, advocate, and a caregiver for my late Mom, you have perfectly described how I see quality but I would list communication as my #1 priority.

    Imagine if doctors and nurses communicated honestly with compassion to their patients about their limitations without having to worry about litigation. Imagine if the public could trust politicians to speak in plain language their true intentions without us having to insert the word cost for quality for them. Imagine a government that was truly interested in providing healthcare for the public rather than complicating matters further by constantly campaigning to attract or retain votes for their own benefit.

    If all parties were transparent, forthright and accountable and communicated truthfully without focusing mainly on forcing their own agendas at the expense of others, a lot of progress could take place.

    As for Health Quality Ontario I wonder what exactly its purpose is and who is paying attention to its research and recommendations. I always worry when a research organization, even though it is supposed to operate independently, is funded by the Ministry of Health and Long-Term Care because that makes me question the autonomous nature, purpose and results of their work.

    I am on the record as not being a big fan of the MOHLTC and in particular its Performance Improvement and Compliance branch. I always wonder when those who worked at the Ministry end up working for HQO, and I while may be wrong and I admit I have a bias, it causes me to question the relationship and influence that flows between both organizations. Having said that, I agree for all the reasons that you mentioned about HQO that considering the big picture and all the little parts within it is a good idea. Trust in the healthcare system, in its advisors and decision-makers is a barrier to hope for me and many others in the public.

    As a patient and advocate for elderly and infirm residents in long term care and hospitals, I certainly don’t have the answers but I see the need to find them. I would suggest we continue to have these conversations, agree to listen to others and hope our definitions of quality can be modified and combined to best serve the needs of the most vulnerable. I define the most vulnerable as any person whose health is in jeopardy and in need of competent and kindly care in a timely manner. If we could count on that happening then quality and trust in the healthcare system could make a great recovery!


Mark MacLeod


Mark Macleod is an orthapedic surgeon and the past president of the Ontario Medical Association. He lives in London, Ontario.

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