The many faces of quality

10 World Health • 47th Yeor, No.5, September-october 1994 The many faces of quality Hannu Vuori Quality of health care has many faces: an experiential face that the patients judge, a professional and scientific face assessed by the health care providers, and an economic and managerial face controlled by the health care managers. Every body wants high quality health care. As health care providers, we want to produce it; as patients, we want to get it; as health politicians and tax payers, we want to have value for money. But what is quality of health care? Can it be measured? Are there effective ways to improve poor quality? Will such improvement use up resources that might be better used to improve, say, access or equity? Inevitably, the funds available are limited. You cannot get everything you wish but will have to make compromises. You will also have to heed the needs and wishes of others since many people contribute to quality- health professionals, health care managers, health politicians, Community participation is not ;ust a slogan; it can help to solve common problems. patients and their relatives. Which qualitative aspect you emphasise depends on who you are, what you use the services for and the amount of money you have at your disposal. A long list of desirable character- istics is bound to result in high costs and conflicting expectations. For instance, patients may prefer small local hospitals and health centres because they are close to the users; the managers may find them waste- ful; and the health professionals may find them at variance with their wish to work in technologically advanced centres. The combination of charac- teristics selected for the definition of quality depends on who has the greatest prestige and power. Norm- ally, physicians have. It is therefore not surprising that quality is defined by professional or scientific-techni- cal standards. This definition has guided most activities, the acceptable level of quality changing as medical know-how increases. In spite of its widespread use, the professional definition has increasingly become subject to criticism because it starts from the values and goals of one group only, neglecting those of the patients and managers, it stresses technology and can therefore in- crease costs, and it can maintain outdated treatment practices. Medical know-how is one important determinant of quality, but how patients feel is important too. World Health • 47th Year, No. 5, September-Dctober 1994 11 i.e. the costs of not doing the right thing, right first time. The cost of accepting poor quality is always higher than the costs of resolving the problem. Quality of health care has many faces: an experiential face as viewed by patients, a professional and scien- tific face assessed by the health care providers, and an economic and managerial face controlled by the health care managers. Health professionals may be too quick to define quality by scientific and technical standards alone. Will such an array of different, often conflicting expectations allow a meaningful definition of quality of care and effective means to improve it? The answer is "yes", provided we accept a simple definition of quality assurance: solving together common problems. Little say by the patients If quality is synonymous with medical know-how, it will rest completely in the hands of the providers. Patients will have very little to say as they cannot judge the application of professional knowl- edge. This approach can also jeopar- dize other desired goals of health care, particularly equity and adequacy. To reduce the risk of professional dominance, the latest approach is to stress the patients' views on quality. This notion comes straight from business life where the customer is the king. While addressing some shortcomings, this approach in the context of modern health care has the problem of satisfying many cus- tomers who have different, often conflicting, needs and wishes. The patients and their relatives are the most obvious customers, but so are the referring physicians- particularly if they also manage the budget. Many countries have separated the roles of purchasers and providers. If this is the case, the purchasers are also customers whose needs the provider will have to satisfy. Many hospitals systematically survey the opinions of the patients, but it is difficult to base concrete actions to improve quality on the results of such surveys. The views of the patients tend to change as the treatment progresses. What they want is not necessarily what they need. Advertisements, the experi- ences of friends or relatives and so forth may have induced them to demand services that will not benefit them or will be unduly costly. Yielding to such demands might result in giving popular but ineffec- tive, even harmful treatments or in giving the right treatment in the wrong way. It takes a professional to judge what the medically defined needs are, what is the best treatment, and how to carry it out. On the other hand, care of unnec- essarily high technical quality wastes resources and thereby deprives other patients of necessary services. Here the managers enter the picture. They have to design and run the services in such a way that waste, duplication and mistakes will be minimized. The managers will also have to see to it that services are being provided within existing limits, financial or otherwise, and directives. The re- sulting management quality can be measured in terms of quality costs, Quality is not an absolute but a relative notion. The current ap- proach for equitable health care as we enter the 21st century combines the expectations of the consumers, providers and managers and stresses: • the individual situation; • the needs and wishes of the con- sumers; • the costs; • reasonable professional and scientific standards; and • the right level of optimization, not maximization. • Dr Honnu Vuori is WHO Special Representative to Former Yugoslavia, WHO Area Office, Zogrepconka, 12th floor, Sovska 41 , 41000 Zagreb, Croatia. The points of view of both doctors and patients ore equally important if the optimal quality of core is to be attained.