Two Faces of Health Care Quality Improvement. (Research Notes)

By Jennings, Bruce | The Hastings Center Report, January-February 2003 | Go to article overview

Two Faces of Health Care Quality Improvement. (Research Notes)


Jennings, Bruce, The Hastings Center Report


The attention of specialists in health policy has been focused on a very interesting worldwide "movement" in health care called Quality Improvement (QI). It bears watching. QI has the potential to be one of the best things that has happened to American health care in decades. Or it may prove to be merely one more driving force in the de-professionalization of medicine in the twenty-first century.

QI grows out of the work of management consultants in the 1970s who were trying to make American industries and products more competitive. A group of health policy experts began to draw upon those ideas of "total quality management" and import them into the running of hospitals, nursing homes, and doctor's offices. At the same time, there was a focus in medicine on outcomes research, medical practice variations studies, and evidence-based medicine. For the watchdogs of managed care, quality was on the agenda because they feared that the rewards for reducing costs would drive down quality as well. More recently, the shocking discovery of the number of medical errors and injuries that occur in American hospitals has fueled interest in QI.

Thus QI has become organized, credentialed, and institutionalized. A federal agency exists to promote it, the Agency for Healthcare Research and Quality. The Institute of Medicine has issued two book-length reports on the field. And the powerful Joint Commission on the Accreditation of Healthcare Organizations has helped force institutional change and establish quality improvement efforts within hospitals.

QI comes into medicine like Janus, looking backward and forward at the same time. We will see a bit of both faces in the coming years. Still, these two directions are worth distinguishing as bioethics becomes involved in the quality improvement conversation.

QI may be simply a contemporary extension of the approach to management often called "Taylorism," after the founder of scientific management research and time-motion studies, Frederick W. Taylor. This approach emphasizes highly centralized management practices and tightly controlled, narrowly defined assignments. If this backward face of QI predominates, then doctors, like their colleagues in the engineering profession before them, may lose what remains of their control over the conditions of their practice. Esoteric professional knowledge and judgment will give way to statistically validated general knowledge. Professional self-regulation will bow to formal legal and bureaucratic regulation. Charisma and idiosyncracy will be reduced to routinized and rule-governed process. …

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