History of the Quality of Medical Care

Quality improvement programs are frequent in the field of healthcare. However, the methods, criteria of assessment, scales of evaluation, and, most importantly, the results of such programs vary wildly and are almost as numerous and diverse as the number of establishments and organizations which attempt them. The reason for this is the lack of a unified approach to quality assessment. In fact, such a unified approach is not only non-existent but extremely unlikely.

For instance, the Triple Aim approach exhibited by the Institute for Healthcare Improvement takes the most intuitively understandable approach by focusing on the patient outcome. Three aspects of the outcome are considered, namely the individual quality of care, the health of the population, and the cost of healthcare services. The latter is notably oriented towards regions with high poverty rates and sets the accessibility of care as a criterion alongside patient outcomes. The overview of the Triple Aim does not specify the methods of the data gathering, but it is logical to assume that at least the population health is assessed via clinical records and other indirect methods (Donabedian, 2005). Finally, the individual assessment includes the patient satisfaction into the process, considering the social aspect of quality. It is worth mentioning that while the central criteria are accounted for, the Triple Aim completely omits the economic and financial sustainability. While this is acceptable if a separate entity is controlling the financial domain, such an approach can only produce a focused rather than a concise analysis, which limits its applicability.

On the opposite side of the spectrum is the approach suggested by the Baldrige Excellence Framework. While it includes the patient satisfaction and the performance of the organization (in our case – the quality of health care services), it also lists four criteria focusing on the internal operations, such as the chosen strategy, the workforce, the operations, and the leadership. Such an approach clearly allows for better organizational activities, but may leave behind some of the crucial health outcomes. According to Donabedian (2005), the number and importance of the criteria for patient health are so numerous and diverse that their selection and evaluation become a sufficient challenge, which eventually leads to the shortcomings of the analysis. We can thus conclude that the approaches by Malcolm Baldridge and the Institute for Healthcare Improvement only marginally intersect in terms of the assessed areas and present enough differences to be successfully used by different departments, with the former being more suitable for organizational management and providing more options for increasing sustainability.

However, when taken in the context of healthcare, one common thread connects all of the approaches, which is the patient-oriented approach. The Triple Aim achieves it directly by assessing the health outcomes and satisfaction, while the Baldridge program includes the workforce efficiency and operational costs (which influence the outcomes indirectly). Historical examples also include the use of the quality management techniques which were initially intended for industrial use, such as Deming’s quality principle, Juran’s motivational approach, and the concept of Zero Defects by Crosby (Komashie, Mousavi, & Gore, 2007) Of the three, only the Juran’s approach explicitly emphasizes the customer satisfaction, with all three focusing on performance. Thus, they are not suited for the healthcare field as they do not account for the subtle details of patient health and give little attention to the social aspects of the target audience, which is why the attempts to use them were unsatisfactory (Komashie et al., 2007).


Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Quarterly, 83(4), 691-729.

Komashie, A., Mousavi, A., & Gore, J. (2007). Quality management in healthcare and industry: A comparative review and emerging themes. Journal of Management History, 13(4), 359-370.

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