Why Can't We Define Good Quality Care?

This fall, I am teaching the Law and Ethics for Healthcare Professionals course at the University of North Carolina – Wilmington in the Master of Healthcare Administration program.

The course begins with an introduction to the history of hospitals dating back to ancient Egypt. For their first assignment, students are asked to reflect on how hospitals have driven discoveries and innovations that have led to improved quality and outcomes. Things like hand washing and its role in preventing infections or keeping patients with communicable diseases from staying in the same room or ward with patients present for surgical procedures.

While I have some grumbles about the premise of the question (which focuses exclusively on the role of the hospital in care delivery and innovation), it wasn’t mine to design, so I work within the parameters, providing the students with a variety of sources to get a diverse perspective on this topic.

In doing so, I kept returning to the question: What even is quality? What do we mean when we say “good quality care?”

In answering this for my class, I will, of course, share the high-level definitions: Quality of Care is defined as the care that “increases the likelihood of desired health outcomes.” Furthermore, it must be timely, efficient, equitable, and integrated (again, according to the World Health Organization’s operating definition). But what does that actually mean in application? How do we measure it?

In my musings on this question, I thought back to my days in Washington, DC, when I was on Capitol Hill and working for various policy advocacy organizations. I remember making a list of measures that I was certain providers in Accountable Care Organizations had to report on. That list was…long, the idea being that if you don’t measure it, then no one will pay attention to doing things the right way. More than a decade later, I look back and sigh. I’ve learned so much since those salad days.

And yet, I still can’t tell you what “quality” is and how we should assess whether it is present. And I suspect, despite the fact that we spend so much time, money, and effort collecting, analyzing, and reporting quality and performance data on more measures than I can keep track of, that I am not alone in this. As consumers, we mostly can’t really say whether Provider A or Health Insurer B is providing patients high-quality care. Yes, I can check out how hospitals are performing on Hospital Compare where over 150 quality measures are reported. I can do the same for Medicare Advantage plans using the most recent Star ratings.

Is this what quality is? Is that how we should measure it?

But clinical measures and controls, even the most straightforward ones (the non-occurrence of “never events” like sponges left in surgical cavities) do not guarantee outcomes. And surely, both as consumers of health care and as payers, our understanding and valuation of “health” is greater than any single diagnosis or care interaction.

Perhaps then, as quality seems to be a retrospective assessment, is it really the health of our communities that should be the measure of quality in health care? When I look at what is measured in the county health rankings each year, these measures align more with my expectations of quality. Thinking about quality in this way requires a fundamental shift in so many things. I appreciate the work of the Robert Wood Johnson Foundation in this area through their Public and Community Health program. We need much more of this thinking and work.

We spend so much money collecting, analyzing, and reporting quality data. Can that time, money, and effort be used differently to get more meaningful information?

So, not having answers myself, I turn to you: What are you doing to define quality? How do you think we should measure it?