An issue that gets lots of attention when we think about the healthcare system is quality of care and how to improve it. There have been quite a few studies over time, that have pointed out in one way or another opportunities to improve quality and care. Providers, insurance companies, government regulators, all these and more get involved in efforts to strengthen, and improve the care that gets delivered. Let's take a look at some of the issues in that area. We'll focus here on some of the basic constructs, and ideas that come up around quality in Healthcare, and can guide our thinking. One place to start is with what quality of care even is or what it means. It can clearly have a bunch of dimensions. One framework that has gotten some traction. Points out six domains of quality. This became widely known in a report on quality from the US Institute of Medicine, since renamed the National Academy of Medicine published in the early 1990s. The six domains they pointed out where 1, health care should be safe, it should avoid causing harm. 2, it should be effective, it should provide services based on scientific knowledge to everyone who could benefit, and now provide services to those not likely to benefit. 3, it should be patient centered. It should be respectful and responsive to the preferences, and needs, and values of each individual patient. 4, it should be timely, care should be available with sufficient timeliness that reduces harmful waits and delays. 5, it should be efficient, healthcare should avoid waste. And 6, it should be equitable. We should provide care that is not inappropriately vary, because of personal characteristics like gender, ethnicity, geographic locations, socioeconomic status, or things like that. If you want an acronym, sometimes people use STEEEP, S-T-E-E-E-P. Safe, timely, effective, efficient, equitable, person centered. Out of order from what I just told you, but those work better as an acronym that way. Why take time to walk through that? Well, if you're interested in quality, or looking for ways to work on quality, it's important to keep in mind that there are many dimensions to think about here. Quality is way more than just not making errors, or providing basic safety in medical care. We're probably better now at some dimensions than others, which can leave big opportunities for new efforts, and innovations in different areas. A second useful framework to keep in mind is overuse, underuse, and misuse. This framework reminds us that quality shortcomings, and opportunities in any area really, can come when we use too much healthcare. Can happen when we don't make enough use of things that could be beneficial. Or they can happen when we use things in the wrong way, or at the wrong time. We need to get all three right. Quality is not just about preventing mistakes, or making sure not to forget something. It can be easy for example, to overlook the potential for problems to arise because of overuse. But in fact, some research suggests that this can be a very important dimension of our quality challenges these days. The third framework that informs a lot of thinking about quality these days, and it's useful to mention here is structure, process, outcomes. By the way, some people call this the Donabedian model, naming it after the fellow who originally developed it years ago. It has of course, three parts. The first is structure. In order to get high quality care, we need first to build structures to facilitate that, strong organisations, with the right people, and the right infrastructure for example. Then second, we need to follow the right processes. The steps people take in delivering care should be the right ones. Healthcare providers and in fact the healthcare system more broadly, needs to do the right things, get the right processes. Finally we can look at the outcomes that reproduced, are the effects of healthcare what we want? Is health status being improved for example? Structure, process, outcomes, involves the conceptual progression. A key starting point for quality, is to have a good structure in place. If you have that, then we hope this can lead to a good process of care delivery, or at least help people implement and carry out good processes. And then if there are good processes within a good structure, then we hope that good outcomes will be obtained. Structure and process are steps to getting good outcomes, which is likely the ultimate goal. Finally, the last concept set I'll mention, emphasizes teams as opposed to individuals. Healthcare is often delivered in teams with multiple people, and organizational structures. It's important for individuals to be well trained, and focused on quality of course, but it can also be very important to get the teams and organizations to work well. Relying only on efforts at the individual level, may leave us short of where we could get, by also building strong structures and teams. Can we make systems for example, that prevent errors by individuals, or detect and correct them efficiently if they do happen? These can be powerful ideas. So there are four conceptual structures that guide a lot of our thinking about quality, and that you'll often find coming up around quality in healthcare.
