Re: What is quality?

["Anton O. Tolman, Ph.D." <ANTON@wsh.state.wy.us>]

Loren Bawn wrote:

> I'm not sure the patient needs knowledge of the critical elements to judge
> quality. Do we care what all had to happen to make a hotel stay pleasant?
> If we define quality of knowledge processes as outcome (as perceived by the
> customer), then do we at least have a starting point?    For instance, if a
> diagnosis helps me understand myself better and what condition is causing me
> difficulty, and allows me to understand the goal of the interventions, and
> communicate with my health care professionals my assessment of the success
> or failure of those interventions, have I not received a quality diagnosis?

I think Myron has helped to answer some of this with regard to the different
"levels (professional vs. customer) involved in service quality.  At the same
time, I am not sure that you *have* received a quality diagnosis.  If
everything seemed to be going well -- you think you understand yourself
better, you are communicating well with your care professionals, but then you
drop dead of a stroke because your condition was mis-diagnosed would your
family still consider the diagnosis a quality diagnosis?  I doubt it.

Part of the difficulty in understanding and working in this area is the
complexity of the situation.  You and I may have the same disease, but do not
necessarily present with identical symptoms.  Our symptoms vary depending
perhaps on the stage of the disease, on the interaction of the disease with
other aspects of our health, with other genetic elements, etc.  This is also
true for treatments -- the best treatments in the world for a given condition
do not cure or even help all those persons who are assumed to have the
condition because of the complexity of the interactions between the
treatment, the person, physiology, the environment, etc.

I believe the same to be true in many other service areas including legal
services, probably hotel services, and I would wager, other areas.

When my wife was experiencing some terrible symptoms, her doctors thought
that it was an eating disorder.  They basically "diagnosed" her with that
condition.  *I* knew it was not, she knew it was not.  We had to keep
pressing and pushing until finally they discovered she was gluten intolerant.
Now things are better.  But how her disease interacts with her diet, her
personality, and her treatment are different than how the same condition
would interact with you or I.

> Then, in order to answer the "by what method" question, we would study those
> who produce and don't produce high quality outcomes in order to demystify
> (or map) the processes they use to produce the outcome,  then determine what
> strategies would allow replication of those processes which have produced
> quality, implement the strategies, study, and so on.  I confess I am
> ignorant of the clinical pathways work you mention.  I did browse the IHI
> website a bit, but wasn't able to glean much from it.  Perhaps it could
> serve as a model for the above activity, though.  Does it seem to you that
> their methods are generalizable?

Yes, I think that I am coming to a conclusion of service quality as the
amalgam of Myron's two levels + outcome review until we come up with
something better.  I think the critical piece that is missing in that triad,
however, is a process focus because in a large sense, those three measurement
aspects are all forms of inspection.  If we *are* able to link specific
processes to specific outcomes, the next stage in service quality analysis
would have to be process mapping and identification of upstream variables
that show some stability and connection to the outcomes of interest.

Look further on the IHI website -- read about the collaboratives.  That is
the ongoing effort.  It is mostly limited to medical care settings at this
point, but they have empirical results, they have standardized methodology or
are developing standardized methodologies and they are deliberately seeking
to create methods and procedures that can and do generalize validly across a
variety of situations.

Anton Tolman, PhD, CPHQ, Psychological Services Manager &
Quality Management Coordinator, Wyoming State Hospital
P.O. Box 177, Evanston, WY  82931-0177
Anton@wsh.state.wy.us    (307) 789-3464
"All great things are done for their own sake."   -- Robert Frost
========================================================================