States of mind: #2 – Quality of care

Quality of medical and surgical care is a profoundly felt need of every patient, of every involved family. Although based on slightly different motivations, the same is requested by those who pay for the care. Therefore, the interest in defining and measuring the quality of provided care is high. This is, however, a highly complex endeavor. It requires in-depth knowledge, differentiation, multiple perspectives and expert judgment.

How can we define “quality of care”?

The Institute of Medicine (IOM) of the US National Academy of Sciences defines it as “the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The same institute identified patient-centeredness as crucial to quality health care. Six patient-centeredness dimensions are proposed stipulating that care must be:

  1. respectful to patients’ values, preferences, and expressed needs
  2. coordinated and integrated
  3. provide information, communication, and education
  4. ensure physical comfort
  5. provide emotional support
  6. involve family and friends

There are instruments capable of capturing and measuring those dimensions (for more details see the paper of Tzelepis et al.), more work is needed, however, to develop and validate more generally (not diagnosis specific) and easily applicable questionnaires for this purpose.

In a landmark paper published 1988 in JAMA, three pillars of quality of care were defined: structure, process and outcome.

Structure denotes the settings in which care occurs. This includes material resources (such as facilities, equipment, and money), human resources (such as the number and qualifications of personnel), and organizational structure (such as medical staff organization, methods of peer review as well as methods of reimbursement).

Process denotes what is actually done when giving and receiving care. It includes the patient’s activities in seeking care and carrying it out as well as the health practitioner’s activities in making a diagnosis and recommending or implementing treatment.

Outcome denotes the effects of care on the health status of patients and populations. Improvement in the patient’s knowledge and health status and / or behaviour, as well as patient’s satisfaction with the received care are included.

How do we measure this?

It is not easy to measure all dimensions of quality of care. While the technical quality of care can be assessed and compared to the best in practice, the interpersonal competence is more difficult to measure: privacy, confidentiality, informed choice, concern, empathy, honesty, tact, sensitivity and a lot more can be captured and measured. However this requires a complex approach, which is not suitable for continuous and longitudinal monitoring of whole departments. Instead, indicators that are easier to measure and to calculate are used in each of the three before mentioned fields (pillars).


The patient and her or his family judge the structure of a heath care facility by way they get to see it when visiting the first time: modern / old, architectonically appealing or not, traffic connections, parking facilities, easiness of physical access, visible technical infrastructure (computers, diagnostic facilities such as echocardiography or radiology machines) appearing at an acceptable standard and last but not least the efficiency of  the whole administrative system.

Health care facilities are supposed to be audited by appropriate control organs (in Switzerland the competent cantonal and federal authorities), as well as international accreditation institutions if deemed appropriate (such as ISO or the US Joint Commission).


The path followed by the patient starting from the confirmation of the indication for surgery, preoperative visits, discussion and explanation, admission, preparation for surgery, surgery, taking care of the family, treatment in the intensive care unit, transfer to the step-down unit and the ward, preparation to discharge and rehab treatment. In this context and especially in cardiac surgery, indication is discussed and confirmed in interdisciplinary meetings, known as ”heart team” meetings. The indication for surgery must not be the decision of one single surgeon, but the documented and communicated result of an interdisciplinary consensus. This guarantees the patient and the referring physician the best available decision regarding the specific treatment modality. Preoperative visits and talks with the patient and if possible with trusted members of the family, during which they get to know the surgeon, the anaesthesiologists and other members of the team, are essential for building a base of trust. There we expect the patients to have their questions regarding all aspects of the treatment duly answered. Each team involved before, during and after surgery have check-lists to abide to and are an integral part of the safety measures.  The presence (or absence) of elements of this process chain can be noted and serves as measure of quality. All this belongs today to process quality and is part of my and our daily routine.


Measuring outcome requires a differentiated and granular approach, as well as adequate metrics for measure, benchmark and compare.

On one side we have differentiated medical indicators and metrics, such as the rate of mitral valve repair in degenerative mitral valve disease or the percentage of postoperative myocardial infarction after coronary surgery. Capturing, analyzing and reporting of such metrics should be a standard in our environment.

In Europe, as well as in the USA, specific programs and institutions were funded and founded for the very purpose of monitoring and improving quality of surgical care.  I name just for the sake of example the National Quality Improvement Program of the American College of Surgeons in non-cardiac surgery and the Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (institute for quality assurance and transparency in health care) in Germany. These and all other similar entities are engaged not only in capturing data, but in improving the understanding of quality and how it can be measured reliably and representatively.

In 2004 the National Quality Forum (USA) released and enforces from then on a nationwide valid consensus on a minimal common catalog of quality measures to be used in cardiac surgery. You can find this publication here.

On the other side, the one of the final impact of what we are doing, there are patient-reported outcome measures (PROMs). PROMs examine through validated questionnaires at distinct time points the patient perspective and the perceived final outcome of our care.  Much work is already done and many specific tools are developed and validated for patient reported outcome. One of the pioneers in this direction is the International Consortium for Health Outcomes Measurement (ICHOM), which is driving research and development of PROMs in various disciplines. In cardiac surgery, there are two standard validated questionnaires for patients with Coronary Heart Disease and conditions leading to Heart Failure.

There are, however, also some critical weaknesses with PROMs and their validity. Since these instruments are primarily thought to capture differences between before and after delivery of treatment and care, an inherent problem arises with severe conditions lacking symptoms, such as aortic aneurysms or severe asymptomatic coronary heart disease (such as critical asymptomatic stenosis of the main stem of the left coronary artery). It is out of discussion, that those and many other conditions can be fatal if one would wait for symptoms to develop before proceeding to treatment. This is indeed one of the main dimensions of progress in medicine, the evidence-based prophylactic treatment. It can be difficult to obtain a spontaneously positive PROM in a totally asymptomatic patient, who recovers from major cardiac surgery. The only way to achieve this is through careful and multilateral education in the evaluation phase before surgery and through reduction of the physical impact of the procedure (as with minimally invasive approaches).

Institutional surgical volume has been used as a quality measure, maybe because the data that are needed are easy to capture. The use of process measures, risk-adjusted outcome measures of morbidity and mortality and PROMs provides superior information about the quality of care in cardiac surgery. As denoted by the National Quality Forum, surgical volume should not be used as a primary measure of quality if other severity-adjusted and more differentiated outcome measures are available.

Measuring and judging quality of surgical care is complex. Inadequate simplification is counterproductive and leads to wrong conclusions. Therefore, we, care providers, have to do our best to capture, measure analyze and provide adequate and highly differentiated multi-perspective overviews of the quality of care we deliver to our patients and their families.