Issues in Measuring and Improving Health Care Quality
Friedman, Maria A., Health Care Financing Review
HEALTH CARE QUALITY MOVEMENT
Quality has been a topic of attention in American health care since the early years of this century (Donabedian, 1989). Although quality has not been neglected in the intervening years, the focus on quality is a fairly recent phenomenon, beginning in the late 1980s (O'Leary and Walker, 1994). Since then, quality has become a front-and-center issue for providers, payers, and patients.
A number of converging influences account for the accelerated rise of the quality movement in health care today. These include the growth and transfer of quality theories and practices from the industrial sector, concerns about rising health care costs, and changes in the health care industry.
Transfer From Industry
One of the largest influences on the current environment is the growth of quality-management programs, which began to diffuse after World War II in the industrial sector (Laffel and Blumenthal, 1989). During the 1980s, the focus on quality spread beyond the shop floor to the upper echelons of management in manufacturing and white collar businesses (Gehani, 1993). The quality focus is pervasive in all sectors of the economy and is not expected to die out as such previous management "fads" as zero-based budgeting and management by objective. For example, the number of applications for the prestigious Malcolm Baldrige National Quality Award, the winning of which is considered to exemplify the epitome of companywide quality, have more than tripled in recent years. Applications are received from firms in all sectors of the economy, including health care (Gehani, 1993). According to Juran (1993), the 21st century will be the "Century of Quality." It will embody better ways of defining, measuring, and improving the quality of health care.
Quality as it is practiced today in industry and other settings is an amalgamation of theories and practices set forth by a number of individuals. Many of the terms related to quality are used interchangeably, and the lines between distinct theories and practices have blurred (Reeves and Bednar, 1994). In fact, most organizations in the private and public sectors have instituted quality programs based on the teachings of several quality champions (Anderson, Rungtusanatham, and Schroeder, 1994).
It is beyond the scope of this article to compare the work of those who made significant contributions to the quality field. However, a brief overview of the main proponents is provided because various elements have been transferred to the areas of health care organization, financing, and delivery.
W. Edwards Deming (1986) organized his management philosophy around 14 principles. These included management commitment and leadership, statistical process control, continuous improvement of processes, and removal of barriers to employee participation and control of their own quality. Feigenbaum (1963) originated the concept of total quality control and emphasized that quality should be central to all aspects of the organization, from planning to production to marketing. Juran (1964) emphasized planning and product design, quality audits, and orienting quality management toward both suppliers and customers.
Crosby (1984) focused on cultural change and calculating quality costs. He emphasized the savings which can accrue from quality programs that prevent rework, elimination of waste resulting from manufacturing errors, and inspection and testing of defective goods. Crosby believed the savings generated from quality programs outweigh their costs, thus making quality inherently "free."
Ishikawa (1985) stressed training and quality as cost-control mechanisms. He also popularized use of the cause-and-effect or fish-bone diagram, a tool to help systematically identify the roots of quality-related problems. Taguchi and Clausing (1990) extended some extant practices and principles to include the development of customer-based specifications in product creation and provision. …