With the increasing demand for assessment of quality of outcomes in health care, Psychology services must move beyond traditional concepts of quality assurance in developing and monitoring their service delivery systems. In response to an invitation from the Canadian Council on Health Facilities Accreditation, a consortium of national and provincial psychology groups funded a Task Force to develop a prototypical model of quality improvement for Psychology services delivering health care. This paper describes the model developed by the Task Force and discusses its applications in health care facilities.
The cost of providing health care has escalated. However, there is yet no convincing evidence that the health outcomes produced by that care are proportionate to those increased costs. With a shrinking funding base and growing questions about the efficiency and cost-effectiveness of their services, health care facilities are reexamining their historic structures and ways of operating. The results of these examinations have been actual and proposed changes in the organizational structures of health care facilities. Facilities have reduced the numbers of their beds - and the corresponding importance of bed ratings as an index of a hospital's importance. They have proposed substantial changes in the composition and activities of their staff (Shapiro, 1993).
Coincident with these developments, health care administrators and providers have sought new ways of improving the quality of services to their customers that also promise better cost-management opportunities. Of particular interest in this regard are such initiatives as Continuous Quality Improvement (CQI) and Total Quality Management (TQM) (Berwick, Godfrey, & Roessner, 1990). The Canadian Council on Health Facilities Accreditation (CCHFA) has given quality improvement a central place in its last two Standards' revisions, and has explicitly endorsed CQI as a guiding framework in the 1995 Standards' revision.
As much as any health care providers, psychologists have understood the fundamental importance of evaluating the outcomes of the services they offer. Psychology services in health care facilities have borrowed from medical record-based review systems and adopted other structural and process-based measures of quality (peer review, performance evaluation, workload measurement systems) in developingquality assurance systems (Goodman, Goodman, McGrath, & Goldsmith, 1987). Although essential complements to evaluation of quality of outcomes, these traditional process and productivity indicators cannot supply convincing answers to questions about service outcomes. The wave of the next decade in health care is clear: to provide the highest quality of service possible, and to prove that those services are necessary, appropriate, safe, accessible, and cost-effective (Jospe, Shueman, & Troy, 1991).
A Brief History of Quality(f.1)
For much of the history of goods and services production, quality control meant inspection, aimed at protecting the consumer of goods and services from defective products or poor service. Under this dominant view, quality was equivalent to meeting standards, "zero defects", and assuring freedom from error. Within the health care professions, inspection took the form of long apprenticeship training and hurdles to practice in legal requirements for entry into a profession. After admission to practice, professionals became subject to peer review, disciplinary sanctions, and similar accountability systems to assure continued provider competence.
As the processes of producing and delivering goods and services became increasingly complex enterprises, inspection itself was reexamined. A 1931 book by Walter Shewart, The economic control of the quality of manufactured product, heralded a change from focus on the product to focus on the processes of work that produced it.
These new initiatives toward quality improvement reflected a radical shift in the way of thinking about quality of service. …