General Practitioner, Lincoln and Director,Community and Health Research UnitCollege of Social ScienceUniversity of Lincoln, UK
Dr Stephen Gillam
General Practitioner, Luton and Director of Public Health TeachingUniversity of Cambridge, UK
What is quality?
There are three key models of quality in current use.
The quality triad of structure, process and outcome, first described by Avedis Donabedian in his classic paper ‘Evaluating the Quality of Medical Care’ (Donabedian 1966) provides a basic framework for quality improvement efforts. Structure denotes structural inputs such as funding, equipment, staff, guidelines and protocols. Process refers to the processes or actions of practitioners, managers, patients, carers and others in delivering care. Outcome describes outputs and outcomes of care: these may be intermediate (proxy) outcomes such as reductions in blood pressure or true outcomes such as reduced numbers of stroke in the case of stroke prevention.
Safety timeliness, effectiveness, efficiency, equity and patient-centredness (denoted by the acronym STEEEP) are the key dimensions of quality which were described in a landmark report on quality from the US, Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine 2001). These have been refined into the ‘triple aim’ of improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare (Berwick 2008).
These have been refined to safety, effectiveness (and efficiency) and patient experience in the UK Next Stage Review (Darzi 2008).