The quality of health care: the practical clinical view

Quality assurance techniques involving review of charts and performance have been pursued for many years. The establishment of conformance standards, as well as other aspects of QA considered static and non-dynamic, have been subjected to critical analysis by quality workers pursuing a program of total and continuous quality improvement. These new concepts have evolved from a study of industrial methods which have produced perfect products by a process of progressive incremental improvement. The concept of the "bad apple" (which spoils the barrel) has been disparaged by the new quality improvement workers. The contention that deletion of the "bad apple" is a useless procedure is discussed and refuted. The difference between the "rotten apple" (venal or incompetent physician) and the "bad apple" (careless or aggressive physician) is cited. The importance of the physician in the quality process and failure of the quality literature to get physicians involved are discussed. Improvement of physician performance will require changes in basic educational training rather than attempting to improve current performance by rules and standards. In some countries the problem of poor access to the health system by millions of people is at this time a considerably greater problem than lack of quality within the health system. This may be an area toward which quality workers should direct their attentions.