We are living in the era of quality. We expect everything must be based on some defined value and should be developed with quality in mind. So, what is quality, and is it something that can only be felt or something that can be measured. And when we try to improve any system, we are bound to show it in a measurable fashion to see how much difference we have made.
Is quality a measure of excellence? In the business world, quality is seen as a measure of excellence as well as something which is free from defects. In healthcare, the concept may not be as black and white, yet we believe the quality should be seen as a high degree of excellence. The measurement of that excellence is through certain standards that we will talk about later, and thus the quality of care is seen as compliance with those standards already defined. The Institute of medicine describes the quality of care as the “Degree to which health services to individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.
There are multiple ways we can look at the quality and its domains, and the Institute of Medicine has defined quality in 6 domains.
- Safety.
- Efficient.
- Timely
- Effective.
- Equitable.
- Patient-centered.
We all know that the care provided in different institutes varies, and at times in the same institute varies with a different time frame or different circumstances, and this variation is the root of all quality issues. The more consistent care is delivered the closer to quality it ought to be. Although the above quality domains apply to the whole hospital and with a similar token, emergency care should follow the same standards. Emergency care effectively differs from other levels of healthcare in the urgency and complexity of the problems presented to the department.
Avedis Donabedian (7 January 1919 – 9 November 2000) worked on structural and organizational quality measures and has classified the quality into three groups.
- Human, physical, and financial resources to provide healthcare.
- The steps of care provision are adopted by the organization to provide care to the patient.
- The measure of the resulting effect on the health of the patient or population.
Each one of these above groups looks at a certain aspect of health care delivery, and its measurement gives a picture of the quality in that dimension. The most important of the three is the outcome measures, although it depends upon the other two aspects.
The process measures represent the interaction between the system and the patient. The system interacts through doctors, nurses, lab technicians, radiology staff, and so on and so forth. An example of it can be a wait time to be triaged, a CT scan for a head injury, Time lag to see the doctor, and total ED stay from presentation to discharge. The structure measures look at the quality through the focus on resource provision for healthcare delivery. For example, availability of a cath lab for the MI patients, a Neurology consultant presence on weekends, availability of a telemetry bed for the chest pain patients, nurse to bed ratio, and so on and so forth. Lastly, the outcome measures are the most difficult and tricky to evaluate. The variables at work to affect the outcome are too many and difficult to measure their impact in a quantifiable way. Although they are difficult to evaluate, they are the most valid measures as these represent the impact on the healthcare of the individual and the population.
The people working in the Emergency departments need to understand the value of each and should be able to routinely do an audit to see where they stand and where they need to improve in order to create the biggest impact on the quality of the care they provide. In my next article, I will take up the quality domains and explain them in a bit more detail.
Thank you.