Quantification of quality: a commentary.

Across the room I see a box of envelopes stating "250 Quality Envelopes." What does quality signify? The dictionary defines it: peculiar and ssential character; degree of excellence, superior in kind; a social status; and a distinguishing attribute. Further, "quality is a general term applicable to any trait characteristic whether individual or generic." As physicians, we identify quality with the concept of degree of excellence.

Everywhere we turn, we are faced with the designation of quality. In the past, it was something elementary. Now it has been combined with other words and is entirely different. I am concerned about the evolution of the word quality within the context of medicine and about how it evolved within the medical-industrial complex. In the setting of health care reform, govemment, and law, it is assumed to be a clear-cut entity. It is not.

In 1950, Edwards W. Derrfing was invited to speak before the Union of Japanese Scientists and Engineering, and a new discipline was born. He spoke of quality, quality circles, uniformity of product, quality audits, profound knowledge, and the cost of the lack of quality, terms that were in contradistinction to the economic philosophy of that time. Medicine was as slow to adopt these concept as was American Industry. The evolution of the Japanese and American industrial complex is history. We now see cooperative ventures using the best of both cultures.

Once the wisdom of the "quality philosophy" was recognized, a new language appeared in American medicine. Very quickly. new tenns emerged, such as quality assurance, utilization review, risk management, quality management, continuous quality improvement, and the latest and not the last, total quality management.

One of the first organizations to recognize the importance of quantification was the Joint Commission on Accreditation of Healthcare Organizations, which insisted on standardization of data retrieval systems. This promoted the fallacy that the only place high-quality medicine could be practiced and evaluated was in the hospitals.

What does quality denote? It is apparent that the dictionary does not address the current concept of quality. Quality suggests different things to different people. To patients, it may indicate they can have all the medical care they desire. To physicians, it may indicate they can provide unlimited procedures and care without concern for costs. To hospital administration, it could indicate filling, beds to meet desired staffing and budget. To the managed care company, it may indicate decreasing cash outflow.

The current concept of quality in the context of medicine is not quantifiable. It is similar to words such as love, compassion, caring, character etc. Libraries have been filled over the years with books to document these entities.

Soft words that are hard to quantify are the pillars behind which agendas hide. All too often, this is the case with quality. President Clinton. in his speech on health care reform, used six key points - security, choice, quality, savings, simplicity, and responsibility. Five of these points can be quantified to an extent, but quality cannot. Yet, without quality, the other components have no meaning.

Deming's conceptualization of quality is anything, that enhances the product from the viewpoint of the customer. The product has to meet, or improve on, the expectations of the consumer. This concept has been proven to be valid in the marketplace of products and hard goods, but can Deming's concepts be applied to medicine, human life, pain and suffering? Perhaps, if each patient had full knowledge of medical skills and could make medical judgments. However, if everyone, were a trained physician, we would not need physicians in our society. This is obviously not the answer.

If we cannot quantify what quality is, let us discuss what it is not. It cannot be what the customer/patient wants. There is not enough money or resources to provide all the health care needs consumers think they need. It cannot be everything physicians want. Resources are limited. Defensive medicine forces physicians to invest too much for too little retum on the health care dollar.

High-quality medicine is not practiced in hospitals or institutions exclusively. It is not the property of any individual, any institution, any government, or any society. It cannot be enforced by the legal profession, through the courts, or through lawsuits. When the legal system is engaged, total costs go up. It cannot be legislated through state boards or regulatory agencies. It cannot be developed by creating, a new agency or department. The more agencies that are involved, the higher the cost.

Quality cannot be bought with money. History shows that the more money that is put into health care programs, the greater the need. It cannot be provided by the "deep pockets" of the insurance companies or by government bureaucracy.

Quality is not a database. Informatics will be the key to identification of many problem areas in medicine, but it is the individual who must make the change. It cannot be guaranteed or promised. It is something that we approach but never achieve.

If quality is not quantifiable, what is it? if the current definition is not applicable, we must redefine it in a new context. Patients, providers, institutions, and governmment must recognize it is a goal and can be achieved only through a united effort. We must realize that quality is a dynamic process of continuous improvement. It constantly changes as we try to reach out for it. It must come from within and cannot be mandated from without. The collective public must be educated.

Having asked the question, "Can quality be quantified? I must conclude that it cannot. Yes, we can gather data, set parameters and clinical guidelines, and improve the process. But we cannot quantify quality. It becomes problematic when we are called upon by the Congress and the President of the United States to document and quantify quality and the definition and interpretation changes with the mood of the marketplace and each administration. Quality in medicine is in "the eye of the beholder."

The literature is replete with theorefical discussions of medical qualuy managemen4 particularly of the measurement of quahty in the health care setting. While there is a growing body of knowkdge on both quality and its measurement, this author questions whether medical quafity can ever be quantified. He says that the concept of quality is stifl a moving larget, so that the value of attempts at quantification can only be short-lived