November / December 2012
Quality in Healthcare: A Five-Dimensional View
Readers may be familiar with John Godfrey Saxe’s poetic version of the Asian Indian legend concerning the six blind men who each tries to describe an elephant by reaching out and touching the part closest to where he is standing. One touches the trunk, another a leg, one the tusk, and so on; and each describes the pachyderm by what his sense of touch has revealed, and of course none of them accurately describes the elephant.
Quality in healthcare is another kind of elephant, with different structures and continuously moving parts of assessment, measurement, and performance that change over time; thus complicating the calculus. Like the six blind men, different stakeholders reach out to touch quality from dimensions most suitable to their unique positions, but no single stakeholder actually describes the whole. When one considers that the range of stakeholders includes, at a minimum, clinicians, board members, administrators, accreditors, regulators, risk managers, attorneys, technology assessors, the media, and of course patients, the complexity of defining quality in healthcare, in a fashion that everyone can agree on, becomes readily apparent. Stakeholders describe the pieces of quality that are important to their respective guilds, but the actual entire shape of the quality elephant remains elusive.
Rather than struggling to define the undefinable, another approach may be to simply describe the perspectives of quality and leave the portrayal of the whole to the philosophers. Some elements for defining quality in healthcare have been presented in the Institute of Medicine’s (IOM’s) seminal report Crossing the Quality Chasm (2001). The IOM defined 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.” Furthermore, the IOM viewed quality as consisting of six sentinel attributes: safe, timely, effective, patient-centered, efficient and equitable. Those of us with an interest in understanding quality should be looking for metrics of performance that reflect those attributes.
Four Dimensions of Quality in Healthcare
Trying to view quality in healthcare is like looking through a kaleidoscope that includes four distinct colors or dimensions:
- Accreditation and Certification of Hospitals and Community-Based Services
- Clinical Quality Performance Measurement and Improvement
- Patient Safety Assurance and Harm Prevention
- Patient Experiences and Perceptions of Care
In addition, there is a fifth dimension: Time, which means changes in the first four dimensions over time. The continuum of performance measurement over time within each dimension, from historical benchmarks toward achievable goals, through continuous improvement, is really where the vision of true quality in healthcare resides, a vision that best approximates the attributes that the IOM alludes to.
As one turns the kaleidoscope on its axis, one begins to appreciate the interrelationships between the four dimensions of quality and the systems-nature of the whole. Each dimension’s metrics of performance abut or integrate with elements and metrics of the other dimensions; quality in healthcare may actually turn out to be something greater than the sum of its parts.
The four dimensions described below each add clarity to the vision of quality, but none actually enlightens quality in healthcare independently. Healthcare leaders, and the institutional cultures they hope to develop and sustain, must embrace all four dimensions for success; and quality improvement over time, the fifth dimension, is the crucial component warranting focus for leaders of truly outstanding organizations.
Accreditation and/or certification establish the basis for providing quality in healthcare. Accreditation is the foundation upon which healthcare is delivered, but it is not a measure of quality, per se. Institutions and unique special services such as laboratory centers and imaging services must be accredited and must comply with standards of performance and licensure to establish credibility. In the same way, clinical staff must maintain proficiency and currency in accordance with established standards in order to sustain and enhance skills and to insure competency.
However, having achieved accreditation and assurances of performance-based privileging or capabilities to practice does not directly map to providing quality healthcare. Rather it is more about how well an institution or professional has performed in the past and how well the infrastructure for providing quality healthcare has been established. Accreditation and human performance assessments are underpinnings and even possible predictors of future quality performance, but they are not measures of quality in a stand-alone sense. Institutions and professionals must comply with these standards in order to fulfill their obligations to patients and to deserve the honored privilege of caring for patients, but this one dimension of quality in healthcare is insufficient to define the whole.
Clinical performance metrics are generally regarded as “the” measures of clinical quality. Process measures assess what and how care is provided and the appropriateness of care; outcomes measures demonstrate how well care is provided and, potentially, the cost-benefits or cost-efficiencies of those efforts. However, process measures don’t tell us much about meaningful endpoints of care, and many important outcomes are not directly measures of how well institutions or providers function solely but, rather, measure the result of collaborative efforts between clinicians and patients to achieve desired outcomes.
For example, there are several important quality indicators pertaining to the urgent management of patients presenting with symptoms and signs of cerebral ischemia in emergency rooms (Adams et al., 2007). Compliance with these process indicators can be useful metrics of quality performance because they are known to be linked intimately to clinical outcomes such as morbidity, mortality, etc. Holding institutions and clinicians responsible for performance, and the clinical outcomes coincident with their actions, is certainly important and appropriate.
At the same time, holding providers responsible for clinical outcomes may not always be appropriate, especially in chronic illness management where patient compliance and participation in healthcare interventions is essential. In the case of chronic care management, e.g. diabetes, it is not enough to be in compliance with evidenced-based practice guidelines for frequency of measuring hemoglobin A1c or performing foot exams or measuring urinary protein (American Diabetes Association, 2011). More important really is whether the hemoglobin A1c is normal, whether appropriate adjustments in therapy are prescribed to bring the level into the normal range, whether foot ulcers are prevented, and whether proteinuria is prevented or reversed. All of this depends on partnerships between clinicians and patients, and in many ways the patients own the most important parts of the processes leading to desired outcomes. Though clinical outcomes should trump process outcomes, measuring clinical outcomes is very difficult with current claims-based audit systems, and the labor intensity of these efforts degrades their utility.
Demonstrating sustained process and outcomes performance improvement over time is an important dimension of quality, but again is insufficient to describe the whole.
Providing safe care and avoiding harm may be considered components of clinical performance measurement, but the huge challenges that exist in harm-avoidance raise this to the level of special consideration. In the United States, approximately 27% of hospitalized older patients will experience temporary or permanent harm requiring hospitalization and associated variable degrees of morbidity, lasting disability, or death (Dept. of Health and Human Services, OIG, 2010).
Communication factors seem to be consistently at the forefront of correctable causal factors of safety incidents. Processes to standardize important elements of complex care management, including the use of evidence-based guidelines such as the WHO Safe Surgery Checklist, have worked their ways into our practice (de Vries et al., 2010). Still, many institutions and providers have not adopted a systems-approach to understanding safety, implementation of guidelines is incomplete, and incidents and harm have not been systematically reduced (Landrigan et al., 2010).
Most would agree that safety incidents are the circumstances, the insufficient or failed processes that result in, or have the potential to result in harmful events or outcomes (World Health Organization, 2009). Some stakeholders are more interested in the actual outcomes of incidents than in the insufficient processes. So, for example, the frequency of various kinds of healthcare-associated infections, pressure ulcers, or patient falls are important metrics for measurement and reporting, but the frequency of particular process insufficiencies or failures, such as inadequate hand-washing, failures to implement strategies to prevent pressure ulcers, and lack of bedside assistive devices contributing to falls are not as frequently reported.
Those wishing to improve safety are interested in the process insufficiencies or failures, while those reporting upwards to hospital boards or external regulatory agencies are looking more at the outcomes. Hospital executive boards may be interested in harm and risk avoidance with regard to specific outcomes and less focused on the important process insufficiencies that result in harm. However, identification of causal factors and modulation of those factors through appropriate policies and effective training with continuous assessments should be essential functions of leadership in sustainment of a culture of safety and quality within institutions (Corbett-Nolan & Hazan, 2010). Patient safety is a further dimension of quality, but again does not stand alone.
Patient experiences and perceptions of care are essential metrics of patient-centeredness (Davis et al., 2005). Patients view quality in ways very different from clinicians. Patients deserve to receive compassionate care in a timely fashion, in comfortable settings, via convenient processes. Unfortunately, some patients may confuse “wants” and “needs” and may compliment and even revere the physician who prescribes inappropriate and ineffective medications for illnesses or who orders imaging studies with no focus on appropriateness and little regard to hazards.
For example, nearly 75% of adults diagnosed with upper respiratory tract infections receive antibiotics despite the fact that the overwhelming majority of such infections are caused by viruses (Hirschman, 2002). Imaging investigations are viewed as the cusp of high quality technology, but many are unnecessary, and overutilization exposes patients to the consequences of radiation exposure (Fazel et al., 2009). In addition, the identification of dubious incidental findings may result in additional investigations and even surgical interventions.
Patient experiences and perceptions, though very important, are not stand-alone measures of quality in healthcare.
Quality in healthcare is best defined through the mosaic of these four dimensions and their abutments and interrelationships—a systems approach that eludes “silo-thinking.” In this calculus, stakeholders, like the six blind men, may describe quality differently, but together their descriptions approximate the whole. Improvement over time, the fifth dimension of quality, is the quintessential dimension, and institutions must embrace all of these perspectives as stepping-stones in the quality journey.
Daniel Cohen is international medical director for Datix, a clinical risk management software company. He was formerly chief medical officer for the U.S. Department of Defense TRICARE Healthplan covering more than 9,000,000 beneficiaries. In that capacity, he had oversight for clinical quality and patient safety. Cohen trained in pediatrics and hematology/oncology at the Boston Medical Center (Boston University) and the Children’s Hospital and Dana Farber Cancer Institute (Harvard University). He is a senior fellow of the Royal College of Paediatrics and Child Health (UK) and a fellow of the American Academy of Pediatrics. Cohen is a member of the Editorial Advisory Board for Patient Safety & Quality Healthcare and may be contacted at