As early as the mid-1800s, Florence Nightingale was drawing the world`s attention to the lack of hospital facilities and high mortality statistics and advocated health outcomes as an indicator of quality of care. In the medical field Dr. Ernest Codman was perhaps the first to talk about “end result analysis.” Only in recent years, with the federal government`s increased involvement in the reimbursement of health care costs, has there been a persistent demand for assuring quality.
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At “the heart” of the service professions of medicine and nursing there has always been the desire to give quality care. Without measurable standards, however, defining quality of care is impossible. One nurse may think that she has given quality care after giving a complete bed bath, changing the bed, feeding the patient, and giving a back rub. Another nurse may feel that she has given the same patient quality care after assisting the patient to bathe, arranging the food so that the patient can feed himself, and assisting him in a short walk. Variables are abundant and there is no agreement on what the patient needs in order to progress toward health : in fact, without agreement about what “health” is for this patient, the term “quality care” is nebulous.
Quality refers to the degree of excellence inherent in a person, thing, or action. Quality in measured by stating what actions are desired in giving care and then determining a way to measure whether or not the actions or outcomes were achieved.
Perhaps we ought to first consider the following obstacles to accurately evaluating outcomes in health care :
1. Society and the professions, such as medicine and nursing, have a “social contract.” Society grants the profession authority over specific functions and permits considerable autonomy. In turn, society expects the profession to act responsibly, but society has not had criteria with which to evaluate the effectiveness of this assigned responsibility.
2. The highest quality of care might be given, but the outcome may be poor simply because medical science may not have the answers to the cause of the disease (such as multiple sclerosis) or because the patient`s physical or mental state may not respond to the treatment given.
3. The outcome criteria may be irrelevant to the patient`s problem; for example, when survival is the outcome criterion used but disability rather than death is the usual result (such as in arthritis).
4. Many factors other than medical care influence outcome, for example, family size, health status prior to illness, or living conditions.
5. Some diseases have periods of remission and exacerbation. True “outcome” may only be measured over a period of many years-more years than are available in the study time.
6. Because legal action against health workers is a constant threat, health workers are going to hesitate about studying and publishing their poor results.
7. Colleagues in any professional group have difficulty evaluating each other.
References :
Palmer, Irene, “Florence Nightingale : Reformer, Reactionary, Researcher, “ Nursing Research, 1977.
Drosness, Daniel O., Steven Jonas, and Victor Sidel, “The Delivery of Health Care,” Practice of Medicine. Hagerstown, Md.: Harper & Row, Publishers, 1977.
Guralnik, David O., ed., Webster`s New World Dictionary of the American Language(2nd college ed.). New York : The World Publishing Co., 1972.
Phaneuf, Maria, The Nursing Audit : Profile for Excellence. New York : Appleton-Century-Crofts, 1976.
