Case 3 Quality Management 27-09-2022
Definition of quality of care
Donabedian argued that before assessing quality of care it is necessary to define whether
monetary cost should enter the definition of quality. He thus distinguished a “maximalist”
specification from an “optimalist” specification of quality.
- The maximalist specification ignores monetary costs and defines the highest quality
as the level that can be expected to achieve the greatest improvement in health.
- In contrast, in the optimalist specification of quality, very expensive interventions
that do not achieve a great improvement in health would be avoided.
- Initially, Donabedian defined quality of care from a maximalist perspective, while
later he opted for the concept of value, with quality defined as the maximum that is
possible given the inputs that are available.
The IOM definition:
- Includes a measure of scale (degree) and a wide range of elements of care (health
services)
- identifies both individuals and populations as targets for quality assurance efforts
, - recognizes the importance of outcomes without specifying for whom, thus allowing
the possibility of differing perspectives on which values of quality are most
important;
- highlights the importance of individual patients’ and society’s preferences and values
and implies that the patients have been taken into account in health care decision-
and policy-making;
- underlines the constraints placed on professional performance by the state of
technical, medical and scientific knowledge, implying that the state is dynamic and
that the health care provider is responsible for using the best knowledge base
available
Difference between IOM and Donabedian:
- The IOM has narrowed down their definition from improving total patient welfare to
improving health outcomes
- The IOM shifted the focus from patients to individuals and populations (hence
allowing quality of care also to incorporate health promotion and disease prevention)
- IOM added consideration of the perspective of the care receiver (desired outcomes)
- IOM added consistency of care with current standards (and current professional
knowledge)
Currently, we can see a shift where the definition also focus more on cost-effectiveness since
the society became more aware; health outcomes achieved per dollar spent!
Dimensions of quality of care
Dimensions according to Donabedian
- Efficacy: the ability of the science and technology of health care to bring about
improvements in health when used under the most favorable circumstance
- Effectiveness: the degree to which attainable improvements in health care, in fact,
attained
- Efficiency: the ability to lower cost of care without diminishing attainable
improvements in health
- Optimality: the balancing of improvements in health against the costs of such
improvement
- Acceptability: conformity to the wishes, desires, and expectations of patients and
their families
- Legitimacy: conformity to social preferences as expressed in ethical principles, values,
norms, morae, laws and regulations
- Equity: conformity to a principle that determines what is just and fair in the
distribution of health care and its benefits among members of the population
Dimensions according to IOM
Every dimension is important, none is more important than the other
1. Safety: fundamental to providing healthcare. Care shouldn’t harm patients.
2. Effectiveness: how well treatments are carried out compared to how they are
designed. So providing the appropriate level of care based on scientific knowledge.
Definition of quality of care
Donabedian argued that before assessing quality of care it is necessary to define whether
monetary cost should enter the definition of quality. He thus distinguished a “maximalist”
specification from an “optimalist” specification of quality.
- The maximalist specification ignores monetary costs and defines the highest quality
as the level that can be expected to achieve the greatest improvement in health.
- In contrast, in the optimalist specification of quality, very expensive interventions
that do not achieve a great improvement in health would be avoided.
- Initially, Donabedian defined quality of care from a maximalist perspective, while
later he opted for the concept of value, with quality defined as the maximum that is
possible given the inputs that are available.
The IOM definition:
- Includes a measure of scale (degree) and a wide range of elements of care (health
services)
- identifies both individuals and populations as targets for quality assurance efforts
, - recognizes the importance of outcomes without specifying for whom, thus allowing
the possibility of differing perspectives on which values of quality are most
important;
- highlights the importance of individual patients’ and society’s preferences and values
and implies that the patients have been taken into account in health care decision-
and policy-making;
- underlines the constraints placed on professional performance by the state of
technical, medical and scientific knowledge, implying that the state is dynamic and
that the health care provider is responsible for using the best knowledge base
available
Difference between IOM and Donabedian:
- The IOM has narrowed down their definition from improving total patient welfare to
improving health outcomes
- The IOM shifted the focus from patients to individuals and populations (hence
allowing quality of care also to incorporate health promotion and disease prevention)
- IOM added consideration of the perspective of the care receiver (desired outcomes)
- IOM added consistency of care with current standards (and current professional
knowledge)
Currently, we can see a shift where the definition also focus more on cost-effectiveness since
the society became more aware; health outcomes achieved per dollar spent!
Dimensions of quality of care
Dimensions according to Donabedian
- Efficacy: the ability of the science and technology of health care to bring about
improvements in health when used under the most favorable circumstance
- Effectiveness: the degree to which attainable improvements in health care, in fact,
attained
- Efficiency: the ability to lower cost of care without diminishing attainable
improvements in health
- Optimality: the balancing of improvements in health against the costs of such
improvement
- Acceptability: conformity to the wishes, desires, and expectations of patients and
their families
- Legitimacy: conformity to social preferences as expressed in ethical principles, values,
norms, morae, laws and regulations
- Equity: conformity to a principle that determines what is just and fair in the
distribution of health care and its benefits among members of the population
Dimensions according to IOM
Every dimension is important, none is more important than the other
1. Safety: fundamental to providing healthcare. Care shouldn’t harm patients.
2. Effectiveness: how well treatments are carried out compared to how they are
designed. So providing the appropriate level of care based on scientific knowledge.
