From quality assurance to quality improvement

As we are learning to master the methods of quality assurance, a new conceptual approach focused on quality improvement is being advocated. But this new approach is not a derailment for health care practitioners committed to improve patient care quality. Rather, it is a progressive step that builds upon the concepts and methods of quality assurance. Whereas quality assurance tends to focus on correcting problems in patient care quality--especially individual practitioners' problems--quality improvement focuses on finding opportunities to improve quality by changing systems as well as individual practitioner behavior. Whereas quality assurance tends to rely primarily on standards or guidelines for the structures and processes of care and the intensive review of individual cases with undesirable outcomes, quality improvement also utilizes statistical profiles of outcomes, structures, and processes as baselines against which improvement can be measured. Whereas quality assurance may engender defensiveness in an individual practitioner, quality improvement is based on the health care practitioner's professional ethic and pride in providing even better care to patients tomorrow than is possible today. To improve patient care quality, it is necessary to examine the structures, processes, and outcomes of care. The structures and processes can be controlled by the practitioner and organization; the outcomes are the benchmarks against which the effectiveness of the structures and processes can be evaluated. Outcomes in health care are the effects of more than just the structures and processes controlled by the practitioner and organization. Therefore, outcomes are not direct and complete measures of the quality of the care provided. They are instead indicators of performance. These indicators can focus attention on care that lies outside the normal statistical parameters of performance and can provide baselines against which improvements can be measured. The monitoring and evaluation process described in Joint Commission standards is a method for establishing priorities and using indicators to improve the quality of patient care. This method can be used to focus case-based review of care and to establish baselines for continuous improvement. This conceptual approach that emphasizes quality improvement and the use of the monitoring and evaluation process is guiding the Joint Commission's development of clinical indicators and revision of its standards and survey process to help health care organizations in the transition from quality assurance to quality improvement.