Managing Quality in Care

Designing quality systems should start with defining goals and priorities, says Geert Driessen, manager of scientific affairs and education, perioperative and IV care at 3M Germany.

When I began my nursing career in 1978, healthcare seemed simple and safe. If something went wrong, it was considered part of the deal and it was accepted that complications occurred. But when the Dutch Ministry of Health started to work on a quality law for healthcare institutions in the 1990s, attitudes changed and from that moment every healthcare worker talked about 'quality of care' daily.

However, although I believe the introduction of this law in 1996 helped to improve the quality of care in Dutch hospitals, it has also had its disadvantages. Even information on the Dutch Government's audit office (Rekenkamer) website suggests that many Dutch healthcare institutions are sceptical of the relationship between the new certification and the quality of care.

Defining quality

After the new law was introduced, my colleagues and I discussed what quality meant to us. We agreed that there were as many definitions of it as there were healthcare workers.

Professor Avedis Donobedian, an architect in the field of quality in healthcare has defined it as "...a property that medical services can have in varying degrees". Grant Steffen, in his article 'Quality Medical Care: A Definition' published in JAMA, defines it as: "The capacity of an object with its properties to achieve a goal." From these views, one can conclude that the goal, or how much we have achieved from the goal, defines quality.

Therefore it is logical that quality systems start with defining goals as well as the degrees and the processes by which they should be achieved. When it comes to total quality management systems, goals and required processes to achieve them are formulated on several topics (for example, primary healthcare processes, finance, human resources). An important and contemporary goal of quality systems is to ensure, define and improve patient safety.

Fit for use?

What I saw when travelling around the globe is that in an attempt to make healthcare more efficient, the definition of quality was changing towards being 'fit for purpose', meaning that we no longer require the best products for our processes.

Sometimes it even seems as if the best products are now too good. An example of this is the global trend I have observed in day-case surgery. Surgical procedures are often the same as they used to be in a clinical setting. The time for the procedure and recovery time in hospital is reduced to an absolute minimum, while the quality of some of the products used is set at that same absolute minimum too. Healthcare workers from around the globe seem to have forgotten that the desired outcome of our processes (patient safety) can never be better than the sum of the input (healthcare services and products).

It sometimes seems that (in spite of all the initiatives from the World Health Organisation, CDC and others) healthcare is on its way back and healthcare workers worldwide think less about quality than they did in the mid-1990s.

The desired outcome

If the International Federation of Association Football (FIFA) changed the rules for a game in such a way that we would need to achieve a result within 45 minutes instead of the current 90 minutes, this could have a negative impact on the cashflow of football clubs. If I were a club manager in that case, I would 'buy' better players, just to ensure that the desired outcome of the process (winning the match in less time) would be more likely to happen. Of course, in order to achieve the desired result I could also consider hiring a Dutch coach.