Definitions are, in the main, philologically academic exercises, but some forms of knowledge require a more pragmatic level of distinction to advance the evolution of a field of study and its integration into clinical practice. Quality improvement (QI) and quality assurance (QA) are not static and inert terms. Quality refers to the ability of a product or service to satisfactorily meet its purpose or consumer need. Not surprisingly, the appearance of this term coincided with the advent of the corporate transformation of the United States health care industry in the 1950s.1 If you asked a physician in the 1940s what QI or QA meant, he (because MDs were overwhelmingly male) would look at you with suspicion and assume you were speaking of another industry. The concept of quality can itself be a source of confusion. Since its advent in the 1970s,1 the term is essentially a byproduct of a business structure and mindset, not unlike those used in other industries: fast food, airline, and manufacturing, among others. Quality in health care refers to the degree, to which health services for individuals and populations increase the likelihood of desired health outcomes (Table 1).2 High-quality care is “care that is safe, effective, people-centered, timely, efficient, equitable, and integrated”.4
TABLE 1 -
Understanding Quality, Metrics, and Definitions
|Quality of care
||The degree, to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge2
||An organizational framework that involves the analysis of process and outcomes data and the application of systematic efforts to improve performance
||All the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality3
||Progressive incremental improvement of processes, safety, and patient care
||Health care outcomes achieved per dollar spent
|Patient-reported outcome measures
||Any measure or outcomes of a treatment that is reported directly by patients
QA indicates quality assurance; QI, quality improvement.
Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the outcomes achieved per dollar spent.5 Value is a subjective term, but for clinicians, it is measured by the outcomes achieved and not by the volume of services delivered or balance sheets.6 The forces determining the meaning of outcomes or value are always at play, though presumably, everyone wants more money and healthier patients. Neuroscience-specific patient-reported outcome measures are small in number and rarely aggregated.7 In addition, neuroscience patients present a particular challenge due to the underlying functional and cognitive changes that are present before and expected after surgery.6 Therefore, to define value in perioperative neuroscience, objective measures of functional outcomes with patient-reported measures are required. Enhanced recovery for spine surgery, same-day discharge after craniotomy, and delirium reduction pathways are examples of multidisciplinary collaborations and process-oriented innovations to achieve better health care outcomes, quality, and value.
Quality activities are designed to continuously evaluate and improve performance and to evolve with any given set of advances in the field of medicine, science, and management. QI is the framework used to improve care8; QI focuses not only on processes and systems improvement but also on compliance with current practices. QI usually translates into promoting adherence to evidence-based guidelines. QA is intended to be part of an institutional and corporate formation, organization, and structure that enacts processes that safeguard these requirements are met (for patients, clinicians, administrators, and lawyers). In other words, QA is the process that ensures quality.9
QI and QA can take place at many levels and depend on what is being evaluated and who is doing the evaluation. The pursuit of health care quality has been shifting from QA to a framework of continuous QI. The evolution of QA to QI (beginning with corporate control of United States health care systems in the 1970s) is an outgrowth of the need to focus on liability avoidance and the prevention of future errors. The term continuous QI is used to describe the activities that encompass quality.1 It emphasizes that the process is ongoing and always occurring, neither stable nor static, both retrospective or prospective, and constantly striving to improve the quality of patient care. QI does not simply look backward in time to assess health outcomes. Rather, it is represented in the formation, articulation, and dissemination of clinical practice and knowledge, as well as being forward-looking by anticipating the needs of populations and communities. Examples of continuous QI processes in clinical neuroscience include the use of quality measures to monitor best practices for brain monitoring during anesthesia,10 and for the management of external ventricular and lumbar drains.11 In another example, a recent study demonstrated that neurosurgical patients were at increased risk of hypothermia during intraoperative magnetic resonance imaging, leading to poor outcomes.12 These QI initiatives integrate the latest evidence with continuous monitoring of clinical practice, and further incorporate implementation science to provide higher quality care and value.
PUBLICATION OF QUALITY ACTIVITIES FINDINGS
QI is used across health care systems to improve patient care. Within corporate and institutional models, continuous QI seeks to standardize processes and policies to reduce variation in care, achieve predictable results, and thereby improve outcomes for patients, organizations, and health care systems. This standardization is achieved by identifying and addressing causes of variation in health care delivery and in quality measures. During the process of continuous QI, research opportunities are usually identified that can advance professional knowledge and inform future best practices in an institution and beyond.
It is expected that the findings of QI/QA activities might warrant publication, though regulatory requirements should be considered. Planned publication of the results of a QI activity does not in and of itself oblige prior institutional ethical board review of the activity, although it is highly recommended that a formal process and review take place in accordance with institutional guidelines. Some institutions have developed specific processes for the approval of QI projects and may require review to ensure compliance with data protection and privacy regulations. Though clinicians and scientists may use these activities to advance the field and their own careers by publishing data, sharing or generalizing the results of a QI activity does not imply that the activity was researched or was conducted with an appropriate review. However, the systematic use of identifiable data collected for nonresearch purposes (including QI/QA activities) to contribute to generalizable knowledge is considered research. Therefore, if publication of the findings of quality activities requires reanalysis of identifiable data, it is necessary to consult with local ethics review boards. Journals require that ethical and professional standards be met, and formal institutional ethics and/or privacy review are usually required for publication.
INFORMATION TECHNOLOGY AND QUALITY IMPROVEMENT
Innovation in health care is critically important to achieve high-quality, accessible, and efficient care, including for traditionally marginalized communities, communities of color, immigrants, refugees, and those with few resources. Continuous QI should be the norm in contemporary perioperative neuroscience. Health information technology (IT) is a key component of effective QI to facilitate the delivery of high-quality care and ultimately improve patient-centered outcomes. The use of IT innovations can help drive QI processes and can be seen as a natural “next step.” Everything in the perioperative environment is now connected, making it possible to continuously monitor metrics that directly relate to the quality of perioperative care. Health IT tools that support QI enable the measurement, tracking, and socialization of health care delivery performance, and can therefore monitor how refinements to clinical workflow processes affect both overall patient-reported and perioperative core outcome measures. These tools include a comprehensive use of electronic health records that allow for structured data entry, which can be used for data collection and for data extraction, analysis, reporting, and tracking. Electronic health records can also aid the provision of quality care to patients through clinical decision-support tools and reminders to facilitate adherence to best practices, thereby adding another layer of protection from error.
A successful health care system relies on outstanding performance, translated to both service-volume and patient-centered outcomes while maintaining value through efficiency. Success requires defining the core elements of its enterprise while balancing the priorities of different stakeholders and making ongoing adjustments to the system. Continuous QI is vital, dynamic, and fundamental not only to the health care industry, patients, and communities but also to the well-being and ethical practices of health care workers. Those working in perioperative neuroscience should practice conscientiously with these principles in mind to drive continuous improvement in the quality of our work and allow for the evolution, expansion, and application of our accumulated scientific, institutional, and clinical knowledge.
1. Klein TA, Seelbach CL, Brannan GD. Quality assurance. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC.; 2022 Accessed March 9, 2022. https://www.ncbi.nlm.nih.gov/books/NBK557503/
2. Institute of Medicine Committee on Quality of Health Care in A Crossing the Quality Chasm: a New Health System for the 21st Century. Washington (DC): National Academies Press (US) Copyright 2001 by the National Academy of Sciences; 2001.
3. Defeo JA. Juran’s Quality Handbook: The Complete Guide to Performance Excellence, 7th Edn. McGraw-Hill Education; 2016.
4. World Health O Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018.
5. Porter ME. What is value in health care? N Engl J Med. 2010;363:2477–2481. doi:10.1056/NEJMp1011024
6. Luoma AMV, Flexman AM. Value-based care and quality improvement in perioperative neuroscience. J Neurosurg Anesthesiol. 2022;34:346–351. doi:10.1097/ANA.0000000000000864
7. Ghimire P, Hasegawa H, Kalyal N, et al. Patient-reported outcome measures in neurosurgery: a review of the current literature. Neurosurgery. 2018;83:622–630. doi:10.1093/neuros/nyx547
9. Branca M, Longatto-Filho A. Recommendations on quality control and quality assurance in cervical cytology. Acta Cytologica. 2015;59:361–369. doi:10.1159/000441515
10. Lele AV, Furman M, Myers J, et al. Inadvertent burst suppression during total intravenous anesthesia in 112 consecutive patients undergoing spinal instrumentation surgery: a retrospective observational quality improvement project. J Neurosurg Anesthesiol. 2022;34:300–305. doi:10.1097/ANA.0000000000000754
11. Lele AV, Hoefnagel AL, Schloemerkemper N, et al. Perioperative management of adult patients with external ventricular and lumbar drains: guidelines from the society for neuroscience in anesthesiology and critical care. J Neurosurg Anesthesiol. 2017;29:191–210. doi:10.1097/ANA.0000000000000407
12. Wong BJ, Rama A, Caruso TJ, et al. A pilot quality improvement project to reduce intraoperative MRI hypothermia in neurosurgical patients. Pediatr Qual Saf. 2022;7:e531. doi:10.1097/pq9.0000000000000531