Defining of quality

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Social Science & Medicine 51 (2000) 1611±1625

De®ning quality of care
S.M. Campbell*, M.O. Roland, S.A. Buetow
National Primary Care Research and Development Centre, The University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK

Abstract This paper de®nes quality of health care. We suggest that there are two principal dimensionsof quality of care for individual patients; access and e€ectiveness. In essence, do users get the care they need, and is the care e€ective when they get it? Within e€ectiveness, we de®ne two key components Ð e€ectiveness of clinical care and e€ectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomesresulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and eciency. We show how this framework can beof practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the di€erences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of qualityindicators actually includes and measures and, and which are not included. 7 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Quality; Care; HEDIS; NHS

Introduction Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have increased interest in measuring and improving the quality of health care in many countries of theworld. Quality improvement is high on the national agenda both in the UK (Roland, Holden & Campbell, 1999) and in the USA (Schuster, McGlynn

* Corresponding author. Tel.: +44-0161-275-7601; fax: +44-0161-275-7600. E-mail address: (S.M. Campbell).

& Brooks, 1998). There has been a move away from assessing costs and activity to assessing quality with an emphasis on bothecient use of resources and on the e€ectiveness of health care. In the UK this trend has led to an emphasis on both performance measurement and quality improvement for the NHS, and the development of a national performance framework (Department of Health, 1997; NHS Executive, 1999). Within this, clinical governance will form a framework through which `NHS organisations are accountable formonitoring and improving the quality of their services', with the aim of promoting `an environment where excellence of clinical care will ¯ourish' (NHS Executive, 1998a,b). The increasing focus by governments on improving

0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 0 5 7 - 5


S.M. Campbell et al. / Social Science &Medicine 51 (2000) 1611±1625

quality of care requires that the concept is clearly understood. In this paper we de®ne quality of care. We focus speci®cally upon care received by individuals from formal institutional health care systems which individuals or carers have chosen to access. Care in this context refers to care provided by any health care professional. We suggest that there are twodimensions of quality in this context; access and e€ectiveness. In essence, do users get the care they need, and is the care e€ective when they get it? There are two key elements of e€ectiveness Ð clinical e€ectiveness and the e€ectiveness of inter-personal care Ð and both of these should be related to need. These elements are discussed with reference to the structure of the health care system,...
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