In its simplest form, quality management has two aims: the first is to achieve agreement about the characteristics of quality goods and services, and the second is to develop processes to ensure that quality is achieved in an efficient manner (Geboers et al. 1999). According to Berwick (1989), there are two principal approaches to quality improvement: one is to search for the ‘bad apples’ and remove them from the system; the other is to prevent problems before they arise. The ‘bad apples’ approach to quality assessment, also known as ‘quality by inspection’, aims to identify areas of low quality, using methods that are highly sensitive and specific for identifying opportunities to improve quality (Buetow & Rowland 1999). The resulting data describes what is at fault, and who is at fault, but it provides little information about why a lapse in quality has occurred. This is the principle driving many of the quality assurance programs that have been implemented successfully by the manufacturing industry to guarantee the quality of products.

As leaders and managers became more familiar with the principles of the quality movement, they recognised that simple identification of faults with particular parts of the system after a problem occurred did little to improve performance and outcomes. They recognised that preventing problems was a more sensible approach to quality than reacting to problems where and as they arose. The second approach, total quality management (TQM), has evolved as a philosophy and a management approach that can be used across an organisation to promote technical quality and satisfaction in all aspects of performance (Baird et al. 1993; Shalala 1995).

Berwick (1989, p.54) proposed that in order for an individual to value quality and strive for excellence, the organisation must be committed to ongoing improvements because ‘quality fails when systems fail.’ This applies equally to health care as to manufacturing.

This chapter focuses on quality as both an organisational responsibility and a clinical goal. The aims of the quality movement are introduced and the implications and responsibilities for organisations and individuals committed to ensuring quality are discussed. There is a particular emphasis on implementing and monitoring quality initiatives in the clinical setting. The case is put that all health professionals have a role and responsibility to ensure quality care and services.

WHAT IS QUALITY?

Quality is a widely held and strongly embraced principle; however, there is no standard understanding or set of common principles or stated goals that are universally adopted and used to describe quality (Leatherman & Sutherland 1998). One definition of quality used in health is ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’(Lohr et al. 1992, p.120). The impetus for quality in business began in earnest in the 1940s and 1950s, with the focus being to ensure that a product fulfilled its intended purpose (Katz & Green 1992). That definition was subsequently broadened to include compliance with defined standards or specifications. Health services are also committed to providing quality care and the concepts developed by industry have been adapted to measure the performance and outcomes of individuals and organisations.

LEADERSHIP IN QUALITY MANAGEMENT

The provision of safe, effective, appropriate and accessible health care requires continuous quality improvement. While managing some quality problems is straightforward, in the presence of clinicians who may be skeptical about the motives and unconvinced by the evidence and/or the benefits to patients, a systematic sequence of inquiry and action may assist nurse managers to address complex quality problems (Ovretveit 1999).

Porter-O’Grady (1998) has described seven basic rules to assist managers to provide leadership in implementing change. These principles can be adopted, or adapted, by nurse managers for use in a variety of situations that require a review of service provision. First, no individual working in the area is exempt from the requirements to follow best practice and the manager must not sanction through silence the practice of those who disregard the policy. Second, the manager is unlikely to be able to predetermine or predict the path to implementation, rather they will need to call on experience to identify indicators. The effective manager is skilled at anticipating the challenges, identifying the risks, and moving carefully but confidently ahead. Openly engaging the processes of change assists a smooth transition from concept to reality. Third, emphasising patient outcomes rather than the process of providing care may assist clinicians to shift their focus from the tasks and functions that are familiar to them, to develop a ‘vision’ of how care could be delivered. Presenting a clear vision will assist clinicians to commit to achieving the outcomes against which they can measure the quality of care. Fourth, empowering clinicians to recognise their potential, and indeed their responsibility, to contribute to point-of-care decision-making recognises the increasing dependence of organisations on the knowledge of workers. Hierarchical structures work against empowered decision-making, a point that many organisations have recognised and are attempting to redress. However, clinicians are unlikely to be empowered unless managers create opportunities to participate in critical decision-making. Fifth, the manager needs to ensure that organisational structures at ward and unit level promote empowerment of clinicians. Staff must understand that the structure, and the role of the manager, is to support rather than parent members of the team. The seventh principle is to evaluate, adjust and evaluate again. It is difficult for clinicians working with nursing staff shortages and demands for decreased length of stay and other efficiency measures to stay focused on the reasons for the change, and the outcomes of value. Nevertheless, the manager needs to stay focused on the desired outcomes, and continue to see the whole rather than its parts.

The principles described by Porter-O’Grady (1998) are neither complex nor demanding, and they present a framework that managers can apply to the planning, implementation and evaluation of quality initiatives.

MEASURING QUALITY IN HEALTH

Contemporary measures of quality in health represent a fundamental shift from the way quality was traditionally defined when health professionals judged the quality of care (Brook et al. 1996, p.966).

Discussions about quality in health have tended to focus on two aspects of technical excellence: the appropriateness of the services provided and the skill of the provider. Quality is context based, and the expectations differ between people and groups. There are three constituent groups in health: individual patients, patient groups (for example, people with diabetes, the elderly), and the system as a whole. Each group has its goals, priorities and ideas about quality and the standards they expect and accept (Leatherman & Sutherland 1998). Quality in health is also underpinned by the ethos derived from the values and cultures of the health service, the sense of service to all members of the community, and the motivation to improve (Wilson & Goldschmidt 1995). Priorities for quality improvement may vary according to the nature of the service, the organisation’s priorities, and the individuals involved, and at times there may be conflict (Buetow & Roland 1999). For example, ensuring efficiency and effectiveness from the perspective of the health service for a transplant unit, may mean that access and acceptability are compromised from the perspective of patients.

Six concepts have been described against which services or products can be measured: effectiveness, efficiency, equity, access, acceptability and appropriateness (Buetow & Roland 1999). In reality, the components of quality are weighted, and it cannot be taken for granted that there is concurrence between professional and public perceptions of and priorities for quality. According to Klein (1998), equity and access are predominantly about resource allocation, while effectiveness and appropriateness are mainly about clinical practice. The quality of services at the point of delivery to patients depends crucially on the values and processes which direct the organisation. In health, most of the dimensions of quality link clinical and organisational issues, therefore the focus on clinical governance is paramount to those committed to ensuring quality clinical services. One of the problems associated with health services is that policy-makers may have little understanding or appreciation of the interdependency between organisational processes and patient outcomes. The involvement of clinicians in management, as well as clinical policy development, reduces the perception that quality improvement activities are ‘owned’ by management.

A perspective on quality that has recently come to the fore is the degree to which services meet the expectations of patients and other users of health care (Blumenthal 1996a). Consumers of health care expect that health professionals have the technical skills and knowledge to provide appropriate and safe care, and the interpersonal skills to communicate effectively to establish a level of trust, recognise the patient’s concerns and demonstrate tact and sensitivity.

Health professionals have expressed skepticism that the emphasis on quality care will result in improved patient outcomes. The inability of programs to focus on issues considered important to patient care, the absence of evidence that past quality programs have resulted in improvement (Chassin 1996), and the belief that quality improvement is a tool for cost containment or marketing (Blumental 1996b; Chassin 1996; Wilson & Goldschmidt 1995) have been cited as reasons.

Clinicians have also expressed the view that quality programs focus on identifying errors in practice and imposing punitive sanctions rather than addressing the cause of the problem, which is often attributed to the system (Buetow & Roland 1999). Organisational performance is rarely measured as an indicator of quality, when, in fact, indicators such as staff turnover and dissatisfaction (McKee et al. 1998) and customer satisfaction (Miller 1995) are strong predictors of process measures of quality of care.

It is relatively easy to identify what an organisation does well; however, obtaining an understanding of the gaps and deficiencies is not straightforward. Nevertheless, that was the approach taken by the National Health Service (NHS) the United Kingdom to obtain some understanding of the problems that were common across the system. A list of consumer and health provider concerns was developed into a set of aims that could be used by health facilities and units to evaluate the outcomes of quality initiatives (Leatherman & Sutherland 1998). Developing a rationale for quality initiatives, explicit objectives and minimum levels of performance and improvement in the organisation, contributes to a shared understanding and set of common standards.