health care quality health care quality health care quality is a level of value provided by any health care resource, as determined by some measurement. as with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. the goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care. definition health care quality is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes. quality of care plays an important role in describing the iron triangle of health care relationships between quality, cost, and accessibility of health care within a community. researchers measure health care quality to identify problems caused by overuse, underuse, or misuse of health resources. in 1999, the institute of medicine released six domains to measure and describe quality of care in health: safe – avoiding injuries to patients from care that is intended to help them effective – avoiding overuse and misuse of care patient-centered – providing care that is unique to a patient's needs timely – reducing wait times and harmful delays for patients and providers efficient – avoiding waste of equipment, supplies, ideas and energy equitable – providing care that does not vary across intrinsic personal characteristics while essential for determining the effect of health services research interventions, measuring quality of care poses some challenges due to the limited number of outcomes that are measurable. structural measures describe the providers' ability to provide high quality care, process measures describe the actions taken to maintain or improve community health, and outcome measures describe the impact of a health care intervention. furthermore, due to strict regulations placed on health services research, data sources are not always complete. assessment of health care quality may occur on two different levels: that of the individual patient and that of populations. at the level of the individual patient, or micro-level, assessment focuses on services at the point of delivery and its subsequent effects. at the population level, or macro-level, assessments of health care quality include indicators such as life expectancy, infant mortality rates, incidence, and prevalence of certain health conditions. quality assessments measure these indicators against an established standard. the measures can be difficult to define in health care. methods to assess and improve the donabedian model is a common framework for assessing health care quality and identifies three domains in which health care quality can be assessed: structure, process, and outcomes. all three domains are tightly linked and build on each other. improvements in structure and process are often observed in outcomes. some examples of improvements in process are: clinical practice guidelines, analysis of cost efficiency, and risk management, which consists of proactive steps to prevent medical errors. cost efficiency cost efficiency, or cost-effectiveness, determines whether the benefits of a service exceed the cost incurred to provide the service. a health care service is sometimes not cost efficient due to either overutilization or underutilization. overutilization, or overuse, occurs when the value of health care is diluted with wasted resources. consequently, depriving someone else of the potential benefits from obtaining the service. costs or risks of treatment outweigh the benefits in overused health care. in contrast, underutilization, or underuse, occurs when the benefits of a treatment outweigh the risks or costs, but it is not used. there are potential adverse health outcomes with underutilization. one example is the lack of early cancer detection and treatment which leads to decreased cancer survival rates. clinical pathways clinical pathways are outcome-based and patient-centered case management tools that take on an interdisciplinary approach by "facilitating coordination of care among multiple clinical departments and caregivers". health care managers utilize clinical pathways as a method to reduce variation in care, decrease resource utilization, and improve quality of care. using clinical pathways to reduce costs and errors improves quality by providing a systematic approach to assessing health care outcomes. reducing variations in practice patterns promotes improved collaboration among interdisciplinary players in the health care system. staffing research in care homes in england has shown that an organisation's staffing strategy can have an impact on the quality of care. more vacant positions in staff, for example, can lead to a worse rating by the care quality commission (cqc). also, better staff retention can lead to higher quality care. health professional perspective the quality of the health care given by a health professional can be judged by its outcome, the technical performance of the care and by interpersonal relationships. "outcome" is a change in patients' health, such as reduction in pain, relapses, or death rates. large differences in outcomes can be measured for individual medical providers, and smaller differences can be measured by studying large groups, such as low- and high-volume doctors. significant initiatives to improve healthcare quality outcomes have been undertaken that include clinical practice guidelines, cost efficiency, critical pathways, and risk management. clinical practice guideline "technical performance" is the extent to which a health professional conformed to the best practices established by medical guidelines. clinical practice guidelines, or medical practice guidelines, are scientifically based protocols to assist providers in adopting a "best practice" approach in delivering care for a given health condition. standardizing the practice of medicine improves quality of care by concurrently promoting lower costs and better outcomes. the presumption is providers following medical guidelines are giving the best care and give the most hope of a good outcome. technical performance is judged from a quality perspective without regard to the actual outcome - so for example, if a physician gives care according to the guidelines but a patient's health does not improve, then by this measure, the quality of the "technical performance" is still high. for example, a cochrane review found that computer generated reminders improved doctors' adherence to guidelines and standard of care; but lacked evidence to determine whether or not this actually impacted patient centered health outcomes. risk management risk management consists of "proactive efforts to prevent adverse events related to clinical care" and is focused on avoiding medical malpractice. health care professionals are not immune to lawsuits; therefore, health care organizations have taken initiatives to establish protocols specifically to reduce malpractice litigation. malpractice concerns can result in defensive medicine, or threat of malpractice litigation, which can compromise patient safety and care by inducing additional testing or treatments. one widely used form of defensive medicine is ordering costly imaging which can be wasteful. however, other defensive behaviors may actually reduce access to care and pose risks of physical harm. many specialty physicians report doing more for patients, such as using unnecessary diagnostic tests, because of malpractice risks. in turn, it is especially crucial that risk management approaches employ principles of cost efficiency with standardized practice guidelines and critical pathways. patient perspective patient satisfaction surveys are the main qualitative measure of the patient perspective. patients may not have the clinical judgement of physicians and often judge quality on the basis of practitioner's concern and demeanor, among other things. as a result, patient satisfaction surveys have become a somewhat controversial measure of quality care. proponents argue that patient surveys can provide needed feedback to physicians to assist on improving their practice. in addition, patient satisfaction often correlates with patient involvement in decision making and can improve patient-centered care. patients' evaluation of care can identify opportunities for improvement in care, reducing costs, monitoring performance of health plans, and provide a comparison across health care institutions. opponents of patient satisfaction surveys are often unconvinced that the data is reliable, that the expense does not justify the costs, and that what is measured is not a good indicator of quality. the department of health and human services bases 30 percent of hospitals' medicare reimbursement on patient satisfaction survey scores on a survey, known as the hospital consumer assessment of healthcare providers and systems (hcahps). "beginning in october 2012, the affordable care act implemented a policy that withholds 1 percent of total medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and top performers receive bonuses from the pool." technology and security perspective technology also may affect patients' perception of health care quality. a 2015 survey of cancer patients shows that those who have a more positive attitude towards the health information tools from their providers use the tools more and subsequently have a higher perceived care quality from their provider. the same survey also shows that those who believe their provider acts more securely and have a lower level of privacy concern are more likely to have a positive attitude towards the health information tools from their providers and thus a higher perception of the care they received. organizations which determine quality organizations which work to set standards and measures for health care quality include government health systems; private health systems, accreditation programs such as those for hospital accreditation, health associations, or those who wish to establish international healthcare accreditation; philanthropic foundations; and health research institutions. these organizations seek to define the concept of quality in healthcare, measure that quality, and then encourage the regular measurement of quality so as to provide evidence that health interventions are effective. in the united states multiple organizations have established measures to define quality since providers, patients and payers have different views and expectations of quality. this complex situation creates a challenge because most often the measures of quality are not comparable across organizations and there are issues of transferability and merging across systems. consequently, while measuring health care quality for these reasons, high quality longitudinal provides a substantive framework from which health services researchers can work. the centers for medicare and medicaid services (cms) designs quality evaluations, collects quality, and manages funding for the central government medicare and medicaid programs. in 2001, cms started multiple quality initiatives including, but not limited to: the home health quality initiative, the hospital value-based purchasing program, the hospice quality reporting program, the inpatient rehabilitation facilities quality reporting, and the long-term care hospitals quality reporting. cms established initiatives to measure and improve the quality of care for medicaid and chip beneficiaries for services provided under the umbrella of early periodic screening, diagnosis, and treatment program (epsdt), including maternal and infant health, home and community-based services, preventative care, health disparities, patient safety, external quality review, and improving care transitions. for broader quality control, cms also created hospital compare, which is a large public reporting program that measures and also reports processes of care and outcomes for various health care interventions including heart failure, pneumonia, and acute myocardial infarction. the agency for healthcare research and quality (ahrq) is a central government organization which collects public reports of health quality evaluation to increase the safety and quality of health care. ahrq works together with the united states department of health and human services to make ensure that evidence is understood and used by the medical communities to elevate the quality of care. to fulfill its mission, ahrq contracts with several subsites. cms and ahrq have collectively established the hospital consumer assessment of healthcare providers and systems (cahps) survey. the cahps survey collects uniform measures of patients' perspectives on various aspects of the care they receive in inpatient settings. the results are published on the hospital compare website, which may be used by health care organizations and researchers to improve the quality of their services. purchasers, consumers, and researchers may also use the data to make informed business choices. the joint commission accreditation for healthcare organization (jcaho) is a nonprofit organization that assesses quality at multiple levels by inspecting health care facilities for adherence to clinical guidelines, compliance with rules and regulations for medical staff skills and qualifications, review of medical records