International Journal for Quality in Health Care 15:357-358 (2003)
© 2003 International Society for Quality in Health Care
Book review |
An Introduction to Quality Assurance in Health Care
Centre for Excellence Development University of Salford, UK Health Sector Group, European Foundation for Quality Management
Oxford University Press, 2002
0-19-515809-1; 240 pp; $37.95 Hb, $32.25 Pb
It would seem that any discussion about almost any issue in recent times has had to have the word ‘quality’ peppered liberally throughout the exchange. This apparent obsession with a concept that many have argued has no universal language with which to define it has all too often caused confusion and an inability to truly understand what a quality product or service represents. Nowhere is this more apparent than in health care. For some, the acid test of a quality health care service is the survival of the patient, even though this takes no account of the quality of the patient experience during the treatment process. For others it is the successful completion of the procedure, bringing forth the somewhat macabre statement ‘the operation was a success but unfortunately the patient died’. However, Professor Avedis Donabedian brings a refreshing clarity to this important area through a highly readable yet in-depth exploration of the fundamental ingredients that are essential to delivering a quality service within modern health care. He begins by sharing his definition of quality assurance, and in doing so exposes the weakness in the term. In particular he makes the point that it is tempting to follow the view that quality cannot be assured, as it is too nebulous and abstract to be defined precisely. Equally, he suggests that it is easier to submit to the idea that ‘one man's meat is another's poison’. Terms such as ‘continuous improvement’ are, he says, more useful in that they remind us that no level of quality can be totally satisfactory, as the expectations of patients and health care professional are continually shifting upwards. However, he also tells us that the concepts of quality and continuous improvement are not mutually exclusive.
Having established his position in relation to the notion of quality in health care, Professor Donabedian suggests that quality is the product of two factors; one being the science and technology of health care and the other being the application of that science and technology in actual practice. His view is that the quality of health care in practice is the product of these two factors. This product can be characterized by several attributes, which he refers to as the ‘components of quality’. Here Professor Donabedian gives a lucid account of each of these ‘components’. This thoughtful underpinning of the subject gives the reader a firm basis on which to move on to tackle the other elements that are critical to understanding and delivering quality in health care.
With an ever increasing pressure on health care professionals to meet targets and to demonstrate improvement, the decisions regarding what to monitor are complex and numerous. Professor Donabedian suggests that the only reason to monitor activity is to identify those instances or situations where the quality of care falls below that which is expected or desired. He offers us two fundamental ways in which to tackle this issue. Firstly he describes ‘troubleshooting’. Using this method, the problem tends to identify itself and in response we assign an individual with sufficient skill and knowledge to tackle the issue. The second approach he describes as ‘planned reconnaissance’. Here we take steps to find issues that we were not aware of, or only suspected but needed to confirm and document.
Having given us two basic methods with which to monitor performance and quality, Professor Donabedian then goes on to explore the issues that must form part of the monitoring process. These include determining priorities, selecting the most appropriate approach to assess performance, and determining the criteria and standards against which to judge performance. This aspect alone is complex because of the ever-changing attitudes towards health care and the differing views over what is acceptable and what is not. He gives us a critical analysis of the different ways to obtain information and the implications of making a particular choice. His exploration of these issues is both informative and challenging.
Having taken us through the labyrinth of quality monitoring processes and techniques, Professor Donabedian poses the question ‘Does quality monitoring work?’. He then sets out to address the question by raising the vexed issue of behaviour change. He points out that there is no panacea that will help us to successfully bring about changes in the behaviour of those who work within our health care organizations. He does however, suggest that behaviour change is linked to structure and process, and that ‘poor performance is not always linked to individual competence, but may also have much to do with the context in which the performance takes place’. He also makes clear that what he is saying is speculative. He does, however, hit upon a fundamental truth, which is that to bring about improvement we must change the way in which we currently approach our tasks, because if we always do what we always did then we will always achieve what we always have.
Professor Donabedian is clear that the concept of quality can be defined, and as such can be rendered transparent through monitoring and measurement against a standard. Using this information, adjustments can be made and therefore through this process quality can be ‘assured’. As long as science continues to expand the boundaries of what we can achieve in health care, the pressure to ensure that what we do meets the expectations of patients, health care professionals, governments and the numerous other stakeholders will not ease. Likewise, the issue of the quality of the procedures, processes and techniques that accompany these scientific developments will always be a challenge.
In this highly informative work, Professor Donabedian provides the reader with an excellent basis from which to explore further the issues and challenges surrounding the delivery of a quality health care service in the 21st century.
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