Quality Medical Service Quality of Care

Afza.Malik GDA

Quality of Care and Quality Medical Service

Quality Medical Service Quality of Care

Quality of Care,Report of IOM,Components of Quality Process,Challenges to Measure of Quality,Conclusion.

Quality of Care

    Interest in measuring the quality of health care is a recurring theme in the US health care system. Attempts to measure this concept date back to the 1970s and have more recently taken center stage, with the emphasis on reducing costs of care becoming a key focus of the 1980s and 1990s. 

    Care providers today are expected to provide high-quality care at a reasonable cost while attending to the increasing demand by consumers for more information about care choices and the outcomes of specific providers, whether they be hospitals or other providers of care. 

    Gallagher and Rowell (2003) suggested that the provision of outcome-oriented, cost-effective health care is no longer a goal but a mandate. 

    Part of the issue in health care today, according to these authors, is that the costs, processes, and outcomes of care are so inter related and reciprocal that changes in one of these areas may have significant effects on the other components.

Report of IOM

    A recent report by the Institute of Medicine (IOM) stated that “Health care today. harms too frequently and routinely fail to deliver its potential benefits” (IOM, 2001, p.1). This report further states that all health. care should be “safe, effective, patient-centered, timely, efficient, and equitable” (p. 6). 

    In this report four key aspects of the current health care environment have been identified as the underlying reasons for inadequacy of the health care provided in the US 

    These are the increasing complexity of the fields of science and technology, the increasing issues of chronic health conditions, a poorly structured health delivery system, and constraints on capitalizing on the revolution in information technology today. 

    The Institute of Medicine adopted a definition that states that “quality is the degree to which health services for individuals and populations increase the likelihood of desired. outcomes and are consistent with current professional knowledge” (IOM, 2001, p. 244). 

Components of Quality Process

    Patients receive quality care when the services provided are technically competent, provide good communication, share decision making with the patient and family, and are culturally sensitive. 

    Donabedian's model (1980) of quality measurement based on structure, process, and outcome has become the foundation of most current strategies to measure quality of care in health care systems. Using Donabedian's model, quality can be evaluated based on the three components of structure, process, and outcomes (IOM). 

    Using this framework, structural quality evaluates the capacity of the health care structure to provide high quality care. In nursing this requires nurses to evaluate how the unit's structure and that of the larger organization affect quality of care for the patients under their care. 

    Measures of structure have primarily included cost and financial resources required to provide care as well as human resources such as skill mix, staff characteristics, patient severity of illness factors, and environmental factors of the hospital or care agency.     

During the 1970s and 1980s, patient classification systems were developed but never were extensively implemented. More recently, Diagnosis Related Groups and Nursing Diagnoses are frequently used separately or together to describe patient characteristics in research and care effectiveness evaluations.

    A second component of quality is process quality that focuses on the interactions of nurses with their clients. In nursing, a very process focused discipline, we see the historical contribution of care plans as an important process tool, and more recently, critical paths and care maps have added to this process focus. 

    The best process measures are based on research evidence that the process leads to better outcomes for patients. In today's health care system, most attempts to measure quality focus on process evaluation by assessing the appropriateness of care and the adherence to professional standards. 

    Discharge Planning and Case Management are nursing interventions included in the Nursing Interventions Classification (NIC) that focus on achieving quality care through a process format (Dochterman & Bulechek, 2004).

    A third component of quality is outcomes that provide evidence of the effectiveness of the interventions nurses provide for the health problems and concerns of patients. The IOM report states that the best measures of outcomes are those tied to the process of care. 

    Attempts by nurses to enhance quality strategies, such as critical paths and care maps, have challenged the sacred “care plan” in nursing and have shifted nurses thinking from goals to outcomes. Some of these paths and maps have included standardized nursing languages as content areas for nursing. 

    The Nursing Outcomes Classification (NOC) (Moorhead, Johnson, & Maas, 2004) was developed to measure the effectiveness of nursing interventions. Used with the Nursing Interventions Classification and diagnoses from the North American Nursing Diagnosis Association (NANDA) international, the outcomes are designed to measure the effectiveness of the nursing process. 

    Linkage of these three classifications through a recent publication assists nurses and students to use these languages more effectively (Johnson, M., et al., 2001). The NOC has 330 outcomes that measure along a continuum an individual, family, or community state, behavior, or perception in response to a nursing intervention. 

    Each outcome has an associated set of indicators that are measured to determine the patient, family, or community status in relation to the outcome. 

    Examples of some of the outcomes relevant to a discussion of quality are Pain Control, Symptom Control, Quality of Life, Participation in Health Care Decisions, Asthma Self-Management, Cardiac Disease Self-Management, Risk Control, and Knowledge Disease Process. 

    Use of this classification in practice settings with an evaluation of the outcomes achieved provides needed knowledge to nurses related to the effectiveness of the interventions provided and the care planning process. This evaluation of real patient data on outcomes allows for a continual review of the structure, process, and outcomes of nursing care.

Challenges to Measure of Quality

    The current environment is also challenged to meet patient expectations. Because of this, NOC has added 14 client satisfaction outcomes to measure patient perceptions of their care. 

    While many would argue that the patients cannot usually judge quality as well as health providers can, their impression of quality is very relevant to the discussion. Private nonprofit organizations such as the National Committee for Quality Assurance have been created to improve health care.     

This organization evaluates health plans in the areas of patient safety, confidentiality, consumer protection, access, and continuously improvements. They have both accreditation and performance measurement programs that provide information to consumers.


    The challenges to measure quality are not new issues in the health care system, but we are facing intense pressure to provide safe, cost-effective, patient-focused quality health care. 

    Attention must remain on these key factors as nurses and other health care providers develop better structures, processes, and outcome measures to evaluate the effectiveness of the care we provide. This desire for providing quality of care is central to nursing practice.

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