Abstract
ABSTRACT'Quality' is a widely invoked concept in healthcare, which broadly captures how good or bad a healthcare service is. While quality has long been thought to be multidimensional, and thus constitutively plural, we suggest that quality is also plural in a further sense, namely that different conceptions of quality are appropriately invoked in different contexts, for different purposes. Conceptual diversity in the definition and specification of quality in healthcare is, we argue, not only inevitable but also valuable. To treat one conception of healthcare quality as universally definitive of good healthcare unjustifiably constrains the ways in which healthcare can be understood to be better or worse. This indicates that there are limits to the extent to which improvement activities should be coordinated or standardized across the healthcare sector. While there are good reasons to advocate greater coordination in healthcare improvement activities, harmonization efforts should not advance conceptual uniformity about quality.
Highlights
While quality has long been thought to be multidimensional, and constitutively plural, we suggest that quality is plural in a further sense, namely that different conceptions of quality are appropriately invoked in different contexts, for different purposes
To treat one conception of healthcare quality as universally definitive of good healthcare unjustifiably constrains the ways in which healthcare can be understood to be better or worse
Quality is competitively plural: that is, different high-level conceptions of quality can be appropriately invoked in different contexts and serve different purposes
Summary
‘Quality’ is a widely invoked concept in healthcare, and ‘quality improvement’ is a central part of healthcare service delivery. The ‘quality movement’ in healthcare took off in the second half of the twentieth century, when scholars and clinicians started to measure systematically deficiencies in medical care, including iatrogenic harms, the use of unnecessary and ineffective medical procedures, and geographical variation (Berwick 2008) Central to this approach—ideally, at least, if not always in practice—is the use of robust evidence to justify claims that interventions have led to improvements in quality (Marshall, Pronovost, and Dixon-Woods 2013). Identifying some outcomes as better and others as worse requires some account of what good and bad healthcare look like This will involve reference to the goals or purposes of healthcare, and an assessment as to which practices further these goals and which impede them. We explore some of the normative definitions of quality that have been proposed and adopted for use in healthcare improvement practice
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