Understanding healthcare quality strategies: a five-lens framework (2024)

2.1. Introduction

The previous chapter defined healthcare quality as the degree to which health services for individuals and populations are effective, safe and people-centred. In doing so, it clarified the concept of healthcare quality and distinguished it from health system performance. It also explained how the term “quality strategy” is used in this book; however, it did not link the theoretical work behind understanding, measuring and improving healthcare quality to the characteristics of specific quality strategies (or “initiatives”, or “activities” or “interventions”, as they are called elsewhere; seeChapter 1).

Several conceptual frameworks exist that aim at characterizing different aspects of quality or explaining pathways for effecting change in healthcare. However, existing frameworks have traditionally focused on specific aspects of healthcare quality or on particular quality improvement strategies. For example, some frameworks have attempted to classify different types of indicator for measuring healthcare quality (for example, Donabedian, 1966), while other frameworks have contributed to a better understanding of the different steps needed to achieve quality improvements (for example, Juran & Godfrey, 1999). However, no single framework is available that enables a systematic comparison of the characteristics of the various (and varied) quality strategies mentioned in Chapter 1 and further discussed in Part II of this book.

To bridge this gap and facilitate a better understanding of the characteristics of these strategies, and of how they can contribute to assessing, assuring or improving quality of care, a comprehensive framework was developed for this book and is presented here. The framework draws on several existing concepts and approaches, or “lenses”, for thinking about quality assessment and implementation of change, which are discussed in the following sections.

2.2. The first and second lens: three dimensions of quality and four functions of healthcare

The first two lenses of the five-lens framework developed for this book are based on the framework developed by the Organisation for Economic Co-Operation and Development (OECD) for the Health Care Quality Indicators (HCQI) project (seeFig. 2.1). The framework was first published in 2006 (Arah et al., 2006) and updated in 2015 (Carinci et al., 2015). The purpose of the OECD HCQI framework is to guide the efforts of the Organisation to develop healthcare quality indicators and compare results across countries, as part of a larger agenda focusing on international health systems performance comparisons.

Fig. 2.1 “zooms in” on the relevant part of the HCQI framework, which is conceptualized as a matrix with the dimensions of quality in columns and patients’ healthcare needs in rows. The three dimensions of quality (effectiveness, safety and patient-centredness) have already been discussed in Chapter 1; they summarize the most important components of healthcare (service) quality. The four categories of patients’ healthcare needs are based on the most important reasons for which people seek care, following the Institute of Medicine’s influential work on quality (IOM, 2001):

• Staying healthy (‘primary prevention’ in Fig. 2.1): getting help to avoid illness and remain well

• Getting better: getting help to recover from an illness or injury

• Living with illness or disability: getting help with managing an ongoing, chronic condition or dealing with a disability that affects function

• Coping with the end of life: getting help to deal with a terminal illness

The logic behind the inclusion of these needs categories into the quality framework is that patients seek different types of care depending on their needs. For example, in order to stay healthy, patients seek preventive care, and in order to get better, they seek acute care. Similarly, chronic care corresponds to patients’ needs of living with illness or disability, and palliative care corresponds to the need for coping with end of life. Indicators and quality strategies have to be planned differently for different types of services, depending on patients’ needs and the corresponding necessary healthcare. For example, inpatient mortality is frequently used as an indicator of quality for acute care (for example, mortality of patients admitted because of acute myocardial infarction), but it cannot serve as a quality indicator for palliative care, for obvious reasons.

As mentioned above, the OECD HCQI project has used this framework to define its scope and develop indicators for the different fields in the matrix. One of the updates included in the 2015 version of the framework (shown in Fig. 2.1) was that the dimension of patient-centredness was split into the two areas of “individual patient experiences” and “integrated care”. This was meant to facilitate the creation of related indicators and reflects the international acknowledgement of the importance of integrated care (see alsoChapter 1 for a reflection on how the proposed dimensions of healthcare quality have evolved over time). Also, in the 2015 version, the initial wording of “staying healthy” was changed to “primary prevention” to provide a clearer distinction from “living with illness and disability – chronic care”, as many patients living with a managed chronic condition may consider themselves as seeking care to stay healthy (Carinci et al., 2015).

Drawing from the conceptualization behind the OECD HCQI project, the first lens of the framework developed for this book consists of the three dimensions of quality, i.e. effectiveness, safety and responsiveness. The second lens encompasses the four functions of care that correspond to the categories of patients’ healthcare needs described above, i.e. primary prevention, acute care, chronic care and palliative care.

2.3. The third lens: three major activities of quality strategies

The most influential framework used to conceptualize approaches for the improvement of quality – not only in healthcare but in many industries – is the plan-do-check-act (PDCA) cycle, also known as the plan-do-study-act (PDSA) cycle (Reed & Card, 2016). The PDCA cycle is a four-step model for implementing change that has been applied by many healthcare institutions and public health programmes. It also provides the theoretical underpinning for several of the quality strategies presented in Part II of the book, for example, audit and feedback, and external assessment strategies (seeChapters 10 and 8).

The method of quality management behind the PDCA cycle originated in industrial design, specifically Walter Shewhart and Edward Deming’s description of iterative processes for catalysing change. The PDCA cycle guides users through a prescribed four-stage learning approach to introduce, evaluate and progressively adapt changes aimed at improvement (Taylor et al., 2014). Fig. 2.2 presents the four stages of the PDCA cycle as originally described by Deming.

Other quality improvement scholars have developed similar and somewhat related concepts. For example, the Juran trilogy defines three cyclical stages of managerial processes that are often used in discussions around healthcare improvement (Juran & Godfrey, 1999), including (1) quality planning, (2) quality control, and (3) quality improvement. On the one hand, the trilogy draws attention to the fact that these are three separable domains or activities that can be addressed by particular quality interventions (WHO, 2018a). On the other hand, the cyclical conceptualization of the trilogy highlights that all three elements are necessary and complementary if improvements are to be assured.

Similar to the Juran trilogy, WHO defined three generic domains – or areas of focus – of quality strategies that are useful when thinking about approaches addressing different target groups, such as professionals or providers (WHO, 2008): (1) legislation and regulation, (2) monitoring and measurement, (3) assuring and improving the quality of healthcare services (as 3a) and healthcare systems (as 3b). The idea behind specifying these domains was to guide national governments in their assessment of existing approaches and identification of necessary interventions to improve national quality strategies. A focus on these three cornerstones of quality improvement has proven useful for the analysis of national quality strategies (see, for instance, WHO, 2018b).

Based on these considerations, the third lens of the framework developed for this book builds on these concepts and defines three major activities (or areas of focus) of different quality strategies: (1) setting standards, (2) monitoring, and (3) assuring improvements (seeFig. 2.3). Some of the strategies presented in Part II of the book provide the basis for defining standards (for example, clinical guidelines, see Chapter 9), while others focus on monitoring (for example, accreditation and certification, seeChapter 8) and/or on assuring improvements (for example, public reporting, seeChapter 13), while yet others address more than one element. Focusing on the characteristic feature of each strategy in this respect is useful as it can help clarify why it should contribute to improved quality of care.

However, following the idea of the PDCA cycle, these three activities are conceptualized in the five-lens framework as a cyclical process (seeFig. 2.3). This means that all three activities are necessary in order to achieve change. For example, setting standards does not lead to change by itself if these standards are not monitored – and in order to achieve improvements of quality, actors will have to take the necessary actions to implement change.

2.4. The fourth lens: Donabedian’s distinction between structure, process and outcome

Donabedian’s approach to describing and evaluating the quality of care has been widely accepted and is possibly one of the very few points of consensus in the field (Ayanian & Markel, 2016). In his landmark 1966 article “Evaluating the quality of medical care”, Donabedian built on the concept of “input–process–output” used in industrial manufacturing to propose the triad of structure, process and outcome for the evaluation of the quality of healthcare (seeFig. 2.4).

He defined “structure” (or input) as the attributes of the setting in which care occurs. This includes all the resources needed for the provision of healthcare, such as material resources (facilities, capital, equipment, drugs, etc.), intellectual resources (medical knowledge, information systems) and human resources (healthcare professionals). “Process” denotes the components of care delivered, encompassing the use of resources in terms of what is done in giving and receiving care, divided into patient-related processes (prescription patterns, intervention rates, referral rates, etc.) and organizational aspects (supply with drugs, management of waiting lists, payment of healthcare staff, collection of funds, etc.). Finally, “outcome” describes the effects of healthcare on the health status of patients and populations. Donabedian distinguishes between final outcomes, such as mortality, morbidity, disability or quality of life, and intermediate outcomes, for instance, blood pressure, body weight, personal well-being, functional ability, coping ability and improved knowledge (Donabedian 1988).

Fig. 2.4 also visualizes Donabedian’s position that “good structure increases the likelihood of good process, and good process increases the likelihood of good outcome” (Donabedian, 1988). For example, the availability of the right mix of qualified professionals at a hospital increases the likelihood that a heart surgery will be performed following current professional standards, and this in turn increases the likelihood of patient survival.

Accordingly, the fourth lens of the framework adopts Donabedian’s distinction between structures, processes and outcomes. Again, this distinction is useful because several strategies presented in Part II of this book focus more on one of these elements than on the others. For example, regulation of professionals focuses on the quality of inputs, while clinical guidelines focus on the quality of care processes. Ultimately, the goal of all improvement strategies is better outcomes; the primary mechanism for achieving this goal, however, will vary.

2.5. The fifth and final lens: five targets of quality strategies

The final lens in the five-lens framework distinguishes between five different units of focus (or “targets”, from this point forward) of different strategies (WHO, 2008). Quality strategies can address individual health professionals (for example, physicians or nurses), health technologies (for example, medicines, medical devices), and provider organizations (for example, hospitals or primary care centres). Furthermore, quality strategies can aim at patients or at payers in the health system (WHO, 2008). Table 2.1 provides examples of different strategies targeted at health professionals, health technologies, healthcare provider organizations, patients and payers (see also WHO, 2018a). The distinction between targets of strategies is important because the level of decision-making, regulatory mechanisms and relevant stakeholders to involve in planning, implementation and monitoring varies depending on the target.

2.6. Putting it together: the five-lens framework of healthcare quality strategies

Fig. 2.5 presents the five-lens framework, which integrates the different concepts and approaches presented so far. The framework does not assume a hierarchical order of the different lenses: rather, these are meant as five complementary conceptual perspectives; using them in combination can provide a more complete and more actionable picture of different quality strategies.

To reiterate, the five lenses include – moving from innermost to outermost:

1. The three core dimensions of quality: safety, effectiveness and patient-centredness.

2. The four functions of health care: primary prevention, acute care, chronic care and palliative care.

3. The three main activities of quality strategies: setting standards, monitoring and assuring improvements.

4. Donabedian’s triad: structures, processes and outcomes.

5. The five main targets of quality strategies: health professionals, health technologies, provider organizations, patients and payers.

The five lenses of the framework draw attention to the characteristics of different quality strategies and guide the discussion of their potential contribution to healthcare quality in each chapter of Part II of the book. The conceptualization of the framework in terms of concentric cyclic arrows indicates that different strategies combine different features on each lens. However, in general, strategies do not fall unambiguously into one category per lens of the framework – and there are also areas of overlap between different strategies. As such, the framework does not aim to classify quality strategies to a unique taxonomic position; it rather hopes to describe their characteristics in a manner that enables a better understanding of their contribution to quality assurance and/or improvement and their use in different European countries.

For example, using the framework, audit and feedback (seeChapter 10) can be characterized as a strategy that usually focuses on effectiveness and safety in various settings (prevention, acute care, chronic care and palliative care), by monitoring (and assuring improvements) of care processes (for example, adherence to guidelines) of health professionals. By contrast, pay-for-quality (P4Q) as a quality strategy (seeChapter 14) can be characterized as usually focusing on effectiveness and safety in preventive, acute or chronic care by providing incentives to assure improvements in structures, processes or outcomes of provider organizations or professionals.

2.7. Quality strategies discussed in this book

As mentioned in Chapter 1, numerous strategies have emerged over the years claiming to contribute to assuring or improving quality of care. For instance, the OECD lists 42 strategies for patient safety alone (Slawomirksi, Auraaen & Klazinga, 2017), and Table 1.3 at the end of Chapter 1 includes 28 quality strategies; neither of those lists is exhaustive. Given the multiplicity of different quality strategies and the various levels on which they can be implemented, policy-makers often struggle to make sense of them and to judge their relative effectiveness and cost-effectiveness for the purposes of prioritization.

Any book on quality strategies is inevitably selective, as it is impossible to provide an exhaustive overview and discussion. The strategies discussed in detail in the second part of this book were selected based on the experience of the European Observatory on Health Systems and Policies and comprise those most frequently discussed by policy-makers in Europe. However, this does not mean that other not are less important or should not be considered for implementation. In particular, the book includes only one strategy explicitly targeting patients, i.e. public reporting (seeChapter 13). Other strategies, such as systematic measurement of patient experience or strategies to support patient participation could potentially have an important impact on increasing patient-centredness of healthcare service provision. Similarly, the book does not place much emphasis on digital innovations, such as electronic health records or clinical decision support systems to improve effectiveness and safety of care, despite their potential impact on changing service provision. Nevertheless, among the included strategies there is at least one corresponding to each element of the five-lens framework, i.e. there is at least one strategy concerned with payers (or providers or professionals, etc.), one strategy concerned with structures (or processes or outcomes), and so on.

Many different categorizations of quality strategies are possible along the five lenses of the framework described above. For the sake of simplicity, Table 2.2 categorizes the strategies discussed in the second part of the book into three groups using lenses three and four of the five-lens framework: (1) strategies that set standards for health system structures and inputs, (2) strategies that focus on steering and monitoring health system processes, and (3) strategies that leverage processes and outcomes with the aim of assuring improvements.

Table 2.2 also shows the common structure largely followed by all chapters in Part II of the book. First, chapters describe the characteristic features of the quality strategy at hand, i.e. what are its target(s) (professionals, technologies, provider organizations, patients or payers; lens five of the framework described above) and main activity (setting standards, monitoring or assuring improvements; lens three). In addition, each chapter describes the underlying rationale of why the strategy should contribute to healthcare quality by explaining how it may affect safety, effectiveness and/or patient-centredness (lens 1) of care through changes of structures, processes and/or outcomes (lens 4). Secondly, the chapters provide an overview of what is being done in European countries in respect to the specific quality strategy, considering – among other things – whether the strategy is mostly applied in preventive care, acute care, chronic care or palliative care (lens 2). They then summarize the available evidence with regard to the strategy’s effectiveness and cost-effectiveness, often building on existing systematic reviews or reviews of reviews. They follow up by addressing questions of implementation, for example, what institutional and organizational requirements are necessary to implement the strategy. Finally, each chapter provides conclusions for policy-makers bringing together the available evidence and highlighting the relationship of the strategy to other strategies.

2.8. Concluding remarks

This chapter described the development of a comprehensive five-lens framework that brings together influential concepts and approaches for understanding, assuring and improving quality of care. The framework facilitates a better grasp of the key characteristics of individual quality strategies and guides the discussion about their potential contribution to high-quality healthcare in Part II of the book. This discussion of quality strategies hopes to contribute to greater conceptual clarity about their key characteristics and to enable policy-makers to develop national strategic plans on the basis of the best available evidence.

References

• Arah OA, et al. A conceptual framework for the OECD Health Care Quality Indicators Project. International Journal fo r Quality in Health Care. 2006;18 S1:5–13. [PubMed: 16954510]

• Ayanian ZJ, Markel H. Donabedian’s Lasting Framework for Health Care Quality. The New England Journal of Medicine. 2016;375:205–7. [PubMed: 27468057]

• Carinci F, et al. Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. International Journal for Quality in Health Care. 2015;27(2):137–46. [PubMed: 25758443]

• Donabedian A. Evaluating the quality of medical care. Milbank Quarterly. 1966:691–729. [PMC free article: PMC2690293] [PubMed: 16279964]

• Donabedian A. The quality of care. How can it be assessed. Journal of the American Medical Association. 1988;260(12):1743–8. [PubMed: 3045356]

• IOM. Envisioning the National Health Care Quality Report. Washington (DC), US: National Academies Press; 2001. [PubMed: 25057551]

• Juran JM, Godfrey A. Juran’s Quality Handbook. New York: McGraw-Hill; 1999.

• Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Quality & Safety. 2016;25:147–52. [PMC free article: PMC4789701] [PubMed: 26700542]

• Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety. Paris: Organisation for Economic Co-operation and Development; 2017.

• Taylor MJ, et al. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety. 2014;23(4):290–8. [PMC free article: PMC3963536] [PubMed: 24025320]

• WHO. Guidance on developing quality and safety strategies with a health system approach. Copenhagen: World Health Organization (Regional Office for Europe); 2008.

• WHO. Handbook for national quality policy and strategy – A practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018a.

• WHO. Copenhagen: World Health Organization (Regional Office for Europe); 2018b. Quality of care review in Kyrgyzstan.