Quantification of quality: a commentary

The literature is replete with theoretical discussions of medical quality management, particularly of the measurement of quality in the health care setting. While there is a growing body of knowledge on both quality and its measurement, this author questions whether medical quality can ever be quantified. He says that the concept of quality is still a moving target, so that the value of attempts at quantification can only be short-lived.     

Nursing home care: ensuring quality.

There are more than 17,000 nursing homes in the United States providing care for 1.7 million disabled and elderly individuals. Medicare and Medicaid paid $28 billion in 1997 for nursing home services, more than one half of all nursing home expenditures. Improvements in the quality of care in these facilities and ensuring value for public expenditures has been a long sought after goal. Recent actions by the federal government are designed to strengthen state and federal authority and processes to accomplish this goal. Physician leadership in this area is essential to its success.     

Behavioral quality assurance: a transforming experience

The captains of the health care industry are leading a transformation in health care. Increasing numbers of physician executives are acquiring the knowledge, skills, and attitudes essential to both the science and the art of management. If they wish to practice the art of management at a high professional level, however, physician executives must be willing to experiment with their behavior in interactions. Change and growth in this aspect of human nature will also bring them face-to-face with their self-images. More important, attention throughout an organization to behavior toward one another will have a significant bearing on the quality of the organization's services to clients.     

Herding stats: the quality measurement dilemma

All over the country, millions of research dollars are being spent to devise an effective way of measuring quality that could be standardized in health care, and hospitals and managed care companies are experimenting with a variety of quality tools, trying to document what they now can only perceive as improvement. Experts are divided on what works best, but all applaud and embrace the efforts. In this special report, several of them discuss their views on what works, and what doesn't work, in the exploding field of health care quality measurement.     

Hospitals' newest challenge: designing in quality

The job of producing high-quality products is even more difficult for health care providers than it is for those in manufacturing, where the quality movement began. As a part of the service industry, health care providers are in the position of producing products and delivering services at the moment of sale. Our task is to improve the quality of all of these simultaneous and interrelated processes. Traditionally, health care providers have made efforts to improve their products and services without realizing the impact that could be made by also improving resources, processes, and outcomes. This article is an overview of the new direction we have been taking: Retrospective review. Critical pathways. Building quality into all areas (resources, processes, products and services, and outcomes). Focused study of outcomes). We foresee a further evolution that will lead to exciting new methods for understanding and delivering high-quality care.     

Success in managed care: improving clinical quality

What are the economic elements for success in managed care? Although they are quite simple, achieving them can be difficult. The criteria for success in the fee-for-service medical delivery system, generally characterized as "see more--do more--get more," are no longer valid for delivering care in a managed care system. This article identifies the economic elements for success in managed care, and offers a disciplined approach to achieving them, combining both actuarial and clinical expertise.     

The quality debate: Consumer Bill of Rights

Inherent in any discussion on quality for a delivered service is understanding what outcomes you want to achieve and assuring that your consumer agrees. The Presidential Commission's Consumer Bill of Rights supports this principle. Its' goals include: strengthening consumer confidence by providing them with a system responsive to their needs and with a credible mechanism to address their concerns; reaffirming the importance of a strong relationship between patients and their health care providers; and, reaffirming the role consumers play in safeguarding their own health. Striking the balance between cost and quality requires all the stakeholders of the health care system to focus on the true issues that impact quality: outcomes, accountability, and consumer satisfaction, however defined.     

Assessing corporate governance quality: substance over form

After the 2008 global financial crisis and corporate scandals, assessing and improving corporate governance quality (CGQ) is essential. This paper proposes a different approach to evaluate CGQ, to overcome the conceptual and methodological limits of the previous rating systems. It tries to go beyond the objectives of the existing models by suggesting an alternative operating model, (aligned with the new CG guidelines) that provides a concise index for monitoring and decision-making. Using a Fuzzy Expert System (FES), the authors propose a formalized model that: (1) represents all the factors (structural and behavioral) that affect the quality of corporate governance in terms of practical and objective decision-making procedure; (2) is a flexible and useful management tool for supporting the “Board review” and assessing the increase in CGQ associated with particular decisions; (3) supervisors can use to assess CG adequacy by replacing or integrating the experts’ opinions with interviews/questionnaires filled in by directors and managers or through direct observation, as recently suggested by EBA/ESMA. This paper highlights the importance of behavioral features and group dynamics in corporate governance and represents them in an integrated model together with other structural and organizational elements.     

Cost of quality reporting: Some Australian evidence

The study explored the quality management practices, specifically addressing cost of quality reporting, of Australian manufacturers certified to AS/NZS ISO 9000. The findings suggest that firms have responded to the demands of the new manufacturing environment and have implemented quality management initiatives in an effort to gain a competitive advantage in the marketplace. The minority of respondents prepared cost of quality reports. For those firms reporting quality costs, the motivation was to identify high-cost problem areas. Firms not reporting quality costs cited lack of management support and the belief that quality was part of the firm's culture.     

Improving the quality of evaluation participation: a meta-evaluation

This study presents a meta-evaluation of a beta-test undertaken of a customer service training programme. The initial evaluation showed a low level of participation in the beta-test evaluations. Therefore, the meta-evaluation (or an evaluation of the evaluation) focused on issues related to the conduct of the initial evaluation and reasons for non-response. The meta-evaluation identified solutions to the participation problem as related to authority, capacity and motivation.     

Service quality in the legal profession: a review

Research into the management of professional service quality, other than in health care, has been very limited, despite being particularly problematical. This paper focuses on the interactive, highly customized and labour-intensive service offered by solicitors to their commercial and corporate clients. The intangible nature of legal services, the natures of the professionals themselves and the firms within which they operate, and the perceptions of risk brought to the service by the client create additional difficulties in managing the service and measuring client perceptions of it. Yet solicitors must understand the requirements of the group of clients they seek to serve in order to design their service to match those needs. Clients have to assume the technical competence of their solicitor. Moreover, they seek confidence when buying legal services. Our research, therefore, sought to gain an understanding of the process used by commercial and corporate clients when evaluating legal service, and of the factors that are key drivers in the creation of confidence.     

What's ahead on quality: the managed care perspective

Without question, the most important processes occurring in managed care that can be expected to affect quality are accreditation and the effort to obtain and compare uniform information on quality of care across health care organizations, in short, to create "report cards." For both processes, 1993 was an extremely productive year, and 1994 promises to be even more so. These two processes fit hand-in-glove--one is designed to determine that managed care organizations are equipped to serve the public and to implement better health care programs, while the other is designed to help them understand and improve their own performance. Although, in the short run, managed care organizations may view both these efforts as additional costs, in the long run, both should lead to a better industry and to better care for the public.     

From quality assurance to continuous quality improvement

To change from punitive and legalistic QA to positive and productive CQI, both attitudes and methods must change. This is a difficult challenge, but potential rewards for both the organization and its individual members suggest that the effort is worthwhile and deserves high priority. Members of the executive/management team will likely turn to physician executives for guidance on how to proceed.     

Reducing health care costs: a case for quality

Today, it is not quality or access but cost that has become the primary motivator for change in the U.S. health care delivery system. Cost, as the driver, has created a frenzy of nationwide activity, searching, examining, and testing any and all ways that offer promise of financial health care stability. And cost, not quality or access, is the principal motivator for the ever accelerating national health care policy debate. But there is a relationship between costs and quality that has to be addressed if quality is to be maintained.     

Moving from quality assurance to continuous quality improvement

Though numerous proponents of the change from quality assurance (QA) to continuous quality improvement (CQI) have emphasized the drawbacks of the former and the advantages of the latter, there has been relatively little systematic consideration and comparison of the costs and benefits of each. A proper comparison is probably not possible, because the data seem to be lacking. Instead, much of the discourse has been based upon anecdotes, analogies from other industries, and unsupported assertions. This article grows out of a concern that, in making the switch from QA to CQI, we will discard or inadvertently lose much of value in QA and may not achieve many of the things that proponents expect CQI will accomplish. QA has served the health care field well. Its achievements ought to be preserved and built upon, not discarded.     

Total quality management: care dealers vs. car dealers

Let's turn our "flawed system into the Toyota City of world health care," proposes Fortune magazine. I shudder at the thought. Deming-Juran-type TQM procedures can help to ensure that cars and their drivers do not die on the road. Skillfully adapted for health care, these same procedures can help keep patients from dying on the operating table. These procedures can also respond to Fortune's indictment that the "U.S. medical system is as wasteful and managerially backward as Detroit before Henry Ford." However, people are not cars, and care dealers are not car dealers.     

The eternal triangle: cost, access, and quality

No matter who is in charge of health policy, no matter what his or her ideological bent, no matter whether the economy is in boom or bust, three concerns stubbornly dominate the discussion: the cost of care, access to care, and the quality of care. The main variation among them is that normally each in turn receives the most attention from policy makers, payers, and the public, over time.     

Shared planning: a new foundation for quality criteria.

The Chinese word for crisis has two characters. One for danger and one for opportunity. A crisis is a time for awakening to new perspectives and for asking different questions. The widely touted "liability crisis" in the health care field provides just such a time for new approaches. Perhaps there is a way to establish market mechanisms for decision making that gives expression to the desires and values of consumers while respecting the abilities and preferences of physicians. Quality might then be the result of natural selection or, more accurately, of market demand. Such a system would acknowledge that quality in medicine is not for defining. It's for having. Quality should be obtained in bargaining for services, not in mandates of professional regulation.