Quality assurance and outcomes in outpatient parenteral antibiotic therapy.

Quality improvement in medicine has been described as "defining standards of care, reassessing those standards periodically, and continuously improving the medical systems that support those standards." 3 In contradistinction to the previously popular term quality assurance , which was punitive in nature and focused on finding the bad provider or system, quality improvement or performance improvement has as its focus improvement of areas of care that are important , or central, to the organization. If an aspect of care delivered by an organization plays a central role in its system, it should be studied and improved even if it is perceived to be good already. An organization might ask: "What important things do we do well? How can we make them better?" Once these important areas are identified, they are broken down into measurable components and monitored. Strategies for improvement are identified and effects of these strategies are then measured. Results are continuously compared to internal or external standards, or benchmarks. The ultimate result of this activity will be improved value, quality, and outcomes. Over 25 years ago Donebedian 2 defined quality as "the extent to which care provided is expected to achieve the most favorable balance of risks and benefits." He proposed a three-pronged approach to quality assessment: structure, process , and outcome . This framework remains useful today. Structure refers to the setting or organization through which care is delivered. It includes the facility and equipment, personnel with focus on their skills and experience, and basic organizational framework and procedures. Structure does not include the patient as a variable and thus is more easily assessed and modified to improve quality. Areas that can be improved are readily identifiable from outcome measures and periodic external and internal reviews. Changes that are necessary are usually easy to implement. Process refers to the rendering of care and includes selection and assessment of patients, education of patients and implementation of therapy, and ongoing monitoring of therapy with identification of complications or new problems. Process improvement is the core activity of a successful quality improvement program. Processes found within a care system tend to be complex and highly variable. Success requires breakdown of important processes into measurable components and the continuous development of strategies to improve each component. Outcome is the measure of the effects of care on the overall health status of the patient and others. Outcome measurement includes clinical end points and complications but also improvements in patient knowledge and behavior, overall quality of life, and satisfaction. Outcomes are frequently the product of structure and process. Outcomes will drive performance improvement initiatives. These three concepts continue to provide an important framework for the development of a robust performance improvement program. 6 Figure 1 provides an example of how the structure and daily activities of an outpatient antibiotic infusion program may be dissected into its component parts. Each of these elements can be again broken down, measured, and improved. This review focuses primarily on outcome measurement. Publications on techniques and tools for implementing a performance program are readily available. 4,11