March 1995, Volume 45, Issue 3

Editorial

“Quality” in Medical Care: A conceptual Framework

lnayat H. Thaver  ( Faculty of Health Sciences, Baqai University, Karachi. )

Quality assurance and audits are the important compo­nents of an industiy or a business. “Quality” in medical profession is similarly essential forachieving highest possible care at lowest possible cost1. Concerns about quality of medical care must be as old as medicine itself. Among the pioneers of methodical assessment was Florence Nightin­gale2. Quality of care is not the same as clinical efficiency. Medical process incorporates a set of both client and provide behaviours with complex interaction between them which follows use of services and health and weifare of the client. Thus assessment of alt” can be defined as ajudgement concerning the process of care, based on the extent to which that care contributes to valued outcome. Donabedian1 had provided the components of quality of care as: a) structure (physical features of health care); b) process (interaction and activities between doctors and patients) and c) outcome (changes in a patient\\\'s current and future health status). Since then, this concept has been refined by Williamson3 and Doll4. There are however, problems in this type of framework. Even if structure and outcome can be measured, the relation between them is variable and badly defined; structure is an indirect measure5. An alternative approach using ‘structure’ (for assessing quality of care) is to measure the capability of health unit to perform the specific activities and compare it with the standard6. Similarly the causal relationship to changes in health status due to the ‘process’ of care is not easy to establish7. Process variable are relatively easy to identify and have been studied more frequently8. ‘Outcome’ of care is hard to define and may be controversial. The most commonly available variable for outcome “mortality” is too rare to detect the small differences in care and frequently appear too long after the care9.
Lately scope of “Quality” has been broadened to “Quality assurance"10 and “medical 11,12implying not only assessment of quality but also identification of reason for low quality and interventions so as to improve it. Quality has also been assessed from another angle by identifying its dimensions in terms of effectiveness, equity, efficiency and humanity2,10. “Medical audit” has been labelled as “third clinical science13 after biomedical and health care researches because of its pursuance in scientific principles and methodo­logical rigour. Thus a number of synonyms are interchangeably used for “quality” with few modifications5 in their meanings. A conceptual framework for assessing quality of medical care should incorporate “goodness” of technical care14 as well as consumer’s satisfaction15,16. The technical care of the provid­ers is in turn influenced by his/her knowledge and skill and attitudes to an organization of services. In contrast lay images of health, specific goals of consumers and levels of experience of health care, besides the technical care of providers affect the consumer’s satisfaction and hence quality of care of the providers. Assessment of quality of care followed by identification of areas of improvement can help in increasing efficiency of medical care, especially in the private sector. Necessity of assessing quality of care of private practitioners in developed countries was realized in 70\\\'s7,18 and has resulted in marked improvement of their health services. In Pakistan, like in other developing countries where more than half of the population is seeking private medical care19, ensuring good “quality” will help in improving the efficiency of health services. However, it is ver necessary that health professionals should volunteer themselves for “audit”. so as to identify “weaknesses” in management of their practice. This process of assessing the quality of care, cart then, become a necessary requirement for licensing the practice and its annual/biennial renewal by the bodies like Pakistan Medical and Dental Council (PMDC).

References

1. Donabedian, A. Evaluating the quality of medical care. Milbank Q., 1966;44:166-203.
2. Maxwell, R.J. Quality assessment in health. Br. Med. J., 1984;288:1470-72.
3. Williamson, J.W. Evaluating quality ofpatientcare: A strategy relating outcome and process. JAMA., 1971;218:564-69
4. Doll,R. Surveillance and mcinitoring. Int. J. Epidemiol., 1974 ;3:305-14.
5. Shaw, CD. Aspects ofaudit 1. The background. Br. Med. J., 1980;280: 1256-58.
6. Gamer, P., Thomason. J. and Donaldson, D. Quality assessment of health facilities in rural Papua New Guinea. Health Policy Plan., 1990:5(1):49-59.
7. Irvine. D. Managing for quality in general practice. Medical audit series 2, King’s Fund Centrefor Health Services Development, London, 1990.
8. McAuliffe, W.E. Measuring the quality of medical care: Process versus outcome. MilbankQ., 1979;57:118-52.
9. Cleary, P.D. and McNeil, B.J. Patient satisfaction as an indicator of quality care. Inquiry, 1988;25:25-36.
10. Black, N. Quality assurance ofmedical care. J. Public Health Med., 990;12:97­-104.
11. Marinker, NI. Principles in Marinker M. (eds.) Medical Audit and General Practice, London, MSD Foundation by Br. Med. 3., 1990.
12. Hughes,J. andHumphery, C. Medical audit ingeneral practice: A practical guide to the literature. London, King’s Fund Centre for Health Services Development, 1990.
13. Russel, I.T. and Wilson, B.J. Audit: The third clinical science? Quality Health Care, 1992;1 :51-55.
14. Donabedian, A. The definition of quality’ A conceptual exploration. In: Explorations in quality assessment and monitoring. Vol. L The definition of quality and approaches to its assessment. Ann. Arbor Michigan, Health Administration Press, 1980.
15. Pascoe. G.C. Patient satisfaction in primary health care: A literature review and analysis. Evaluation Prog. Planning, 1983;6: 185-210.
16. Cainan, M. Towards a conceptual framework of lay evaluation of health care. Soc. Sci. Med., 1988;27:927-33.
17  Irvine D.H Standards in general practice: the quality initiative revisited. Br. J. Gen. Practice, 1970;40:75-77.
18. Buck, C., Fry, J. and Irvine, D.H. A framework for good primary care: The measurement and achievement of quality. J. R. Coil. General Practitioners, 1974;24:599-604.
19. Thaver, I.H. Whither GPs. (editorial). J. Pak.Med. Assoc., 1994;44:161.

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