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  • Quality is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

  • The ability to measure quality is an essential component to improve quality of care.

  • Quality indicators are used to measure performance, and defined as “norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.”

  • Since quality of care has multiple domains, no single quality indicator can define quality.

  • Quality indicators should be sensitive and specific to the process or outcome in question, measurable, relevant, and actionable by patients, clinicians, and managers.

  • Methodological rigor is necessary to avoid spurious conclusions and provide proper interpretation of quality indicators.

  • Public reporting quality indicators and linking quality indicators to remuneration are increasingly common but may have unintended consequences to the health care system.

  • Quality indicators can be divided into outcome, process, and structural measures.

  • Quality indicators based on outcomes are widely used to compare health systems but are not necessarily sensitive or specific to identify outliers and may lead to biased conclusions.

  • Many structural aspects of intensive care units (ICUs) are associated with patient outcomes, but it is possible for ICUs that do not have these attributes to still perform with high quality.

  • When rigorously and objectively defined, quality indicators based on processes of care can be more informative on specific aspects of quality.


The definition of quality depends on the field being evaluated. For example, although they each provide food and housing, the definitions for high-quality hotels, prisons, and hospitals will be considerably different. The International Organization for Standardization defines quality broadly as “the totality of features and characteristics of a product or service that bears on its ability to satisfy stated or implied needs” (ISO 8402–1986 standard). In health care, quality has been defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 This definition emphasizes two challenging aspects of measuring health care quality: (1) the need to improve outcomes and (2) the importance of evidence. Throughout this chapter, we focus on these two concepts to discuss measuring quality through the use of evidence-based processes of care that should ultimately improve outcomes.


The ability to manage outcomes or processes of care is fundamentally tied to being able to measure them. Finding clinically relevant, measurable, and actionable quality measures enables health systems to act and improve. This is not to say that all important determinants of quality can be measured or that those that cannot be measured should be ignored. Deming, one of the founders of quality metrics, once stated that “running a company on visible figures alone” is one of the seven deadly sins of management....

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