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.