Dear editor In this journal, Crema and Verbano1 discussed the importance of defining quality of health care and how quality can be improved through various industrial instruments and techniques. Quality of health care is a heavily debated topic that requires a wide scope of considerations across the many stakeholders of the health system. We acknowledge Crema and Verbano’s arguments that patient safety is a basic pillar of quality, upon which we would like to expand by highlighting the clinical effectiveness and patient-reported outcomes, which are the two further crucial components of quality. The arguments made regarding quality improvement techniques and cost efficiency in health care provision are insightful, yet appear to make a distinction between efforts to improve quality, eliminate waste from processes, and cut costs in health care provision. We would argue that in fact these achievements are all closely related and can be achieved simultaneously, if the industrial techniques of quality management are applied adequately. Crema and Verbano discuss the importance of focusing on increasing the quality first before addressing reliability and then focusing on cost efficiencies.1 Although this approach is appropriate in highlighting the significance of putting patient safety central in the delivery of health care, there are various limitations to this method as it sees these various improvements as separate processes to be undertaken. A more appropriate way of viewing quality improvement is as an integrated approach to improving safety, reliability, and efficiency in hospital processes, which in turn leads to cost reductions as an effect of the applied improvement strategies. This relies in part on the principle that increased quality in itself is associated with low costs due to the avoidance of litigation costs. Both Feigenbaum2 and Crosby3 describe quality to relate to two distinct costs: conformance (or upholding quality) and nonconformance (or failures). In health care, costs of nonconformance often outweigh those of conformance,4 meaning investments in improving quality will inherently lead to lower overall costs for the system. In 2014, the NHS Litigation Authority paid out £1.1 billion to patients, indicating the huge financial burden that poor quality and patient dissatisfaction can incur on a health service.5 Changing health provision to 1) reduce medical error, 2) improve clinical outcomes, and 3) increase patient satisfaction will therefore inherently lead to cost reduction by the system. Usage of industrial techniques to improve process efficiency has proven to impact both the quality of health care provision and the cost efficiency. The Virginia Mason Medical Center in Seattle, WA, is renowned in the study of health care management for the use of industrial production techniques, specifically the Toyota Production System, to revolutionize the delivery of care at the hospital. Not only did this improve patient safety, in part due to the important patient safety alert system, but also crucially led to a huge capital saving of >$12 million.4 This principle is also seen in Lean Six Sigma projects, which aim to remove waste and inefficiencies from processes. At the University Medical Center in Groningen, a Lean Six Sigma project for the coronary catheterization path-way led to a reduction of 500 inpatient bed days every year, and therefore, a large cost advantage for the organization.6 In conclusion, although we agree with the insightful views provided by Crema and Verbano regarding the definitions of clinical quality, we argue that quality and cost of care in the health sector are not separate factors that should be improved separately. Rather, we suggest that they are inherently integrated with one another, highlighted by Feigenbaum2 and Crosby’s3 definitions of the costs of quality. This implies that industrial quality management techniques do not only lead to improved process efficiency and patient safety but also to measurable cost reductions.
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Jun 8, 2017
John Tingle 
Open Access