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Today’s quality improvement movement in the health care sector draws on disparate roots in medicine and industry.  Regardless of these roots a necessary component of all quality improvement initiatives or accountability programs is feedback from people that receive the service or product.   While this feedback is necessary it is not sufficient for quality improvement, innovation or accountability to take place.  For change to happen the information needs to be acted upon.  The efficacy of actions undertaken by an organization is largely a function of their philosophy and ability with regard to quality improvement and accountability.

 As suggested quality improvement is actualized in different ways depending on an organizations philosophy and ability (see QUINTESSENTIAL QUALITY: DEFINITIONS OF QUALITY).  Nevertheless, for improvement to take place Ishikawa argued that all employees have a greater role to play arguing that an over-reliance on the quality professional limits the potential for improvement.  He maintained that an organization-wide participation was required from the top management to the front-line staff - as every area of an organization can affect quality.  While Ishikawa insisted that total quality means everyone contributes he meant in teams rather than as an individual.  He went on to coin the phrase that quality was a thought revolution and based on the "respect of humanity".  He also maintained that building a quality culture was a slow process easily destroyed by too rapid an implementation and that collecting and analyzing factual data was the essence of quality improvement and innovation.

Like others, Ishikawa believed that quality begins with the customer and therefore the essence of any improvement is based on understanding that customers needs, aspirations and reactions

Regardless of the approach taken some of the benefits of pursuing quality improvement include:

1. Improved service/outcome quality  
2. Improvement becomes the norm.
3. Increased reliability.
4. Reduced costs.
   - Waste, Defects and Rework is identified and reduced (i.e. medical errors).
   - Inspection and after-the-fact expenses are reduced.
5. Improvement techniques are established and continually improved.
6. Organization’s reputation is increased.
7. Interdepartmental barriers are broken down and communication becomes easier.
8. False and inaccurate data is reduced.
9. Meetings are more effective and focused.
10. Improvement in human relations

Quality Improvement in the US and Canadian Health Care Systems

Quality improvement has been advanced in Canada and the United States on two fronts.  Individuals and business organizations that became converts through necessity initially advanced the QI cause. Typically these early converts were in the private sector and adapted QI because of competitive pressures.  Later QI became part of the business school curriculum and later still became part of Public Administration curriculum.   More recently the need to undertake QI has been advanced through legislative authority in Europe, USA and now Canada.  

For instance, Public Law 100-107 (Malcolm Baldrige National Quality Award Act), signed into law on August 20, 1987, created the Malcolm Baldridge Award Program.  Principal support for the program comes from the Foundation for the Malcolm Baldrige National Quality Award, established in 1988.  Health Care sector criteria was introduced in 1997 and the first Baldrige Award for Health Care winner was SSM Health Care in 2002.

Governments in Europe and North America, regardless of political stripe, are increasingly adopting QI approaches and building infrastructure obtain feedback from those that receive their services.  For instance, the Agency for Healthcare Research and Quality (AHRQ) is funded by the THE DEPARTMENT OF HEALTH AND HUMAN SERVICES and developed the Consumer Assessment of Health Plans (CAHP's & H-CAHP's) survey tools.  The federal agency that administers the Medicare, Medicaid and Child Health Insurance Programs in the USA and any providers receiving Medicare or Medicaid funding undertake patient satisfaction surveys using CAHP's tools as part of funding requirements. 

CAHP’s was developed by researchers at Harvard Medical School (Cleary) and Rand Corporation (Hays).  January 15^th 2003 AHRQ will release the next version of H-CAHP’s that is being built with input from major players in the satisfaction tool arena.   Probably the earliest player developing patient satisfaction surveys to support quality improvement is Picker Institute.  The Picker Institute (now Picker Institute Europe) established tools that remain at the forefront of patient survey tools.  Picker has licensed the use of these tools to NRC in North America.  Of interest here is that Cleary, Hays, along with Harvey Picker were also lead researchers in the development of the original Picker tools.  In the USA there is movement towards the adoption of a standardized patient satisfaction survey, the movement is being lead by AHRQ and the CAHP’s tools.

Arriving at a standardized tool set is no small undertaking.  Prior to government involvement many private and non-profit organizations developed to facilitate quality improvement in the health care sector and many developed there own tools and processes.

The National Committee for Quality Assurance (NCQA) is a private not-for-profit organization dedicated to improving health care quality everywhere. The organization is frequently referred to as a watchdog for the managed care industry.  NCQA began accrediting managed care organizations (MCOs) in 1991 in response to the need for standardized, objective information about the quality of these organizations.   More than three quarters of Americans enrolled in HMOs are in health plans that have been reviewed by NCQA.  NCQA also manages the evolution of HEDIS, the performance measurement tool used by more than 90 percent of the nation's health plans.  Health Plan Employer Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. The survey (HEDIS) was changed this year to reflect the CAHPS survey format required by HCFA to measure Medicare populations.

The Institute for Healthcare Improvement (IHI) is a not-for-profit organization driving the improvement of health by advancing the quality and value of health care since 1986.  While this organization has not developed patient satisfaction surveys the organization does support the use of valid/reliable tools and provides training and networking resources to organization that undertake QI.   Canada has similar organizations that support QI through training and networking resoures.  These organizations include the Conference Board of Canada, the National Quality Institute (NQI), the Canadian Evaluation Society (CES), and the Western Healthcare Improvement Network (WHIN).

Finally, like in Canada, numerous accreditation bodies exist in the USA health care sector. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits more than 17,000 health care organizations and programs in the United States. The Canadian Council on Health Services Accreditation (CCHSA) might be seen as providing a similar function in Canada.  In the USA, the American Medical Association (AMA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the National Committee for Quality Assurance (NCQA), are working directly with each other to create integrated performance measurement sets across health plans, provider organizations and practitioners.  In February 1997, JCAHO launched ORYX: The Next Evolution in Accreditation® to integrate the use of outcomes and other performance measurement data into the accreditation process.  JCAHO is striving to make core measures health care organizations as consistent as possible with Center for Medicare and Medicaid Services (formerly Health Care Financing Administration) requirements in order to reduce duplication in performance measurement activities. 

Working towards national standards has also been happening in Canada.  Similarly to JCAHO the Canadian Institute for Health Information (CIHI) has been working on The Health Indicators Project that aims to support Regional Health Authorities in monitoring the health of their population and the functioning of their local health system through quality comparative information.  Like JCAHO in the USA, CIHI is integrating secondary and primary data.  Historically CIHI has been the primary repository for national administrative data and with the advent of the Canadian Community Health Survey (CCHS) the organization has begun to link administrative date to survey research data.  Funding for the CCHS was provided under the Health Information Roadmap initiative, a plan to modernize and standardize health information across the country. The Canadian Institute for Health Information (CIHI) received funds for the Roadmap from Health Canada, and Statistics Canada has joined as a partner in supporting a series of projects.  The CCHS measures patient satisfaction on a two-year cycle.

In January of 2003 the Ontario Hospital Association (OHA) entered into a collaborative working agreement with NRC to use Picker survey tools in Canada.   The OHA has been at the forefront of measuring patient satisfaction in the Canadian hospital setting and recently began outreach with other Canadian jurisdictions to work through them to obtain nationally comparable patient satisfaction data.  The OHA approach is to develop a full suite of service or sector specific tools to measure patient satisfaction and recently announced contracts with NRC and Smaller World Communication (SWC) to undertake these patient satisfaction surveys with other partners across Canada.   

British Columbia is working with the OHA, BC Health Authorities and other jurisdictions to promote the use of standardized service/sector specific survey tools but is also working to develop a core set of patient satisfaction measures available that will reflect a more population health based perspective and realities of regionalization.   The goal is to make these measures as consistent as possible in order to reduce duplication in performance measurement and QI activities undertaken within the Health Care Sector.

In moving forward BC is building on the work done internationally and here in Canada.  No level or sector of Canadian government is immune from the pressure to adopt QI management philosophy and approaches and it would be poor judgment to ignore the experience and work done in other jurisdictions and sectors.  The Canadian Federal Government began it journey down the QI path in the early 1990’s in response to Treasury Board mandate.  The Canadian Federal Government adopted the NQI framework for its map.  The NQI - National Quality Institute – provides the Canadian Quality Criteria for Public Sector Excellence. In 2000, federal, provincial, and territorial representatives of the Public Sector Service Delivery Council agreed to establish the Institute for Citizen Centered Service (ICCS) as an ongoing center of expertise in citizen-centered service. Supported by the Public Sector Chief Information Officers Council and incubated by the Institute of Public Administration of Canada, the ICCS is working with governments across Canada (and around the world) to improve citizen satisfaction with public-sector service delivery. Related Link: Treasury Board of Canada Secretariat.

The Common Measurements Tool (CMT) is an award winning client satisfaction survey tool that has been developed for public sector and maintained by ICCS.  The CMT is easy to use, effective, and will serve to identify client satisfaction, expectations, priorities for improvement, and client service standards.  At present, more than 30 local, provincial, and federal public-sector organizations have adopted the use of the CMT and most recently the Common Measurement Tool Advisory Committee has agreed to work with representatives from Canadian jurisdictions of BC, Alberta, Saskatchewan, Ontario, NWT, Nanavut, New Brunswick and Newfoundland to evaluate the merit of using CMT to meet some of their measurement needs.  BC is spearheading this group’s work in response to the BC’s Ministry of Health service plan and requirements that originate in BC’s Budget and Transparency Accountability Act.  The BC government began to signal its interest in adopting quality improvement practices with the creation Deputy Ministers Council on performance measurement in the early 1990’s.  The work of the CMT-Health Care group will be informed by the work being done by OHA, Picker-Europe and the development of CAHP’s (AHQR).

Again, it must be recognized that agreeing on a standardized tool and/or methodology for measuring and monitoring patient experience of care is a complex task fraught with challenges. Proprietary and academic interests have created a tapestry of survey tools to measure people’s satisfaction with the numerous health services. 

For instance in the USA the Center for Health Systems Research and Analysis (CHSRA) has a significant research interest in the development of indicator/measurement systems which can target problem areas in need of improvement for long term care providers including nursing homes, home health agencies, intermediate care facilities for the mentally retarded and assisted living facilities. 

In Canada the Alberta government works with the Population Research Laboratory at the University of Alberta to undertake annually the public survey about health and the health system.  The Wascana Client-Centered Care Survey-R (WCCS-R) is a tool originally developed by the Regina Health District and is another in a long list of well developed and tested survey tools.   Simply stated – there are as many tools and methods for measuring specific services as there are services.  With the move toward regionalization there has been a increasing need to understand the patient experience from a different perspective; a perspective that incorporates the broad scope of responsibility of the funder (Ministry) and the more holistic experience of those people that use the health care system. 

QUINTESSENTIAL QUALITY: DEFINITIONS OF QUALITY

DEFINING QUALITY TO IMPROVE QUALITY

One of the basic, and perhaps most perplexing questions organizations must answer is, "What is quality?" If this basic definition has stymied your organization's QI efforts, perhaps you can find improve insight in the concepts of quality "gurus."

Philip B. Crosby: The essential elements of quality are as follows: (1) quality must be clearly defined if it is to be managed; (2) someone in the organization must understand the requirements set up by the definition of quality and must be able to translate the requirements into tangible products or services; and (3) measurement of the product or service. Crosby's concepts are further delineated in his book "Quality is free."

W. Edwards Deming: Quality relies on "transformation of the style of American management." This transformation is the subject of his book "Out of the Crisis." According to Deming, the essential characteristics of quality are as follows:

1. Quality is defined in terms of customer satisfaction
2. Quality is multidimensional, which means it must be defined comprehensively and cannot be identified in terms of a single element

A.F. Feigenbaum: Feigenbaum defined quality in terms much the same as Deming's. However he added the concept that the needs and wants of the customers, and hence what will satisfy them, change. Thus quality must be considered to be a dynamic rather than static entity. An excellent "Outline" of the basic components and issues of a modern quality focused organization is presented in his book "Total Quality Control."

Kaoru Ishikawa: Ishikawa also defines quality in terms similar to Deming's. However, he adds the concept that customers will not be satisfied if the price of the product or service is too high, regardless of the quality of that product or service. His concepts of quality are set forth in his book, "What is Total Quality Control: The Japanese Way."

J.M. Juran: Juran defined quality as "fitness for use" in terms of meeting the needs and expectations of the customer, as well as in terms of freedom from deficiency. His views are outlined in "Juran['s Quality Control Handbook."

Robert M. Pirsig: According to Persig, quality is a study in contrasts. For example, he postulated that quality cannot be defined. He then said if you can't define a concept you won't know whether or not it exists. Nevertheless, he asserted that while we can't define quality, we know it when we see it. Pirsig's views are put forth in "Zen and the Art of Motorcycle Maintenance," which the authors of this review recommend as key to readers in the area of quality.

W.A. Shewhart: Shewhart asserted that quality must be defined in both subjective and objective terms. The subjective component is the wants of the customer and the objective, the properties of the product. Like Ishikawa, Shewhart also refers to price relative to quality and perceived value. In addition, Shewhart focuses on the issue of measurability of quality. His book, "Economic Control of Quality of Manufactured Product" delineates the components of value as use, cost, esteem, and exchange. In addition, Shewhart focuses on the issue of measurability of quality.

Source: http://www.ihi.org/resources/eyeoi/2001/8-23abs.asp