towards a conceptual model of ‘quality care’

Pergamon Int J. Nurs. Stud., Vol. 33, No. 1. pp. 13-W 1996

Copyrght c 1996 Elsevier Science Ltd. All rights reserved Printed in Great Bntain

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0020-7489(95)00049-h

Towards a conceptual model of ‘Quality Care’

MOIRAATTREE, M.Sc., B.Nurs., R.G.N., R.N.T., R.H.V., R.D.N. School qf Nursing Studies, Coupland III, University qfklanchester, Oxford Road, Manchester Ml3 9PL. U.K.

Abstract-A model of the multi-dimensional concept ‘Quality Care’ was constructed from data generated inductively from a concept analysis (Attree, 1993). The construction of a model was intended to assist in the clarification of this complex and abstract concept, and permit the exploration of postulated relationships between the elements. The theoretical model could also be used to construct more acceptable and credible measures which would adequately represent the multiple dimensions and perspectives of ‘Quality Care’. It was anticipated that attainment of these initial theoretical stages would form a basis for the development of nursing theory and research relating to ‘Quality Care’.

Introduction

An analysis of the concept ‘Quality’ (Attree, 1993) revealed the lack of both an explicit definition and perhaps more significantly, a shortage of specific criteria with which care quality can be measured. Walker and Avant (1988) assert that in order for abstract and multi-dimensional concepts such as ‘Quality Care’ to be reliably and validly measured the fundamental concept needs to be operationally defined, and the underlying theory made explicit. Before these steps can be undertaken the defining attributes of the concept need to be identified. This endeavour may not, however, be as simple as it appears. Smith (1987) recognised the “difficulty in operationalising such complex variables as quality”; Buchan et al. (1990) proposed that there is no single criterion which defines the quality of a health service, in that quality is “essentially a function of many variables”. Donabedian (1986) concluded that quality is such a “diverse concept that neither a unifying construct, nor a single empirical measure could be developed”.

Evaluation of the prevailing measures of quality care revealed methodological dilemmas. Bond and Thomas (1991), Thomas and Bond (1991) and Koch (1992) remark upon the

13

14 M. ATTREE

dearth of acceptable measures of quality care. Within the literature generally significant reservations were expressed concerning the reliability of quality measuring tools. Giov- annetti et al. (1986) argued that the reliability and construct, content and face validity of the measuring tools are questionable. In their evaluation of the prevailing quality measuring methods Redfern and Norman (I 990) and Harvey (199 1) concluded that the criteria utilised are neither verified nor universally accepted. Balogh (1992) also analysed current British approaches to auditing care quality, criticising them as methodologically weak. Giovannetti et al. (1986) concluded that “virtually all tools developed to date are in need of extensive validity testing, particularly in relation to the concepts of quality they purport to measure”. No clear concept, model or theory of quality was located in the literature suggesting a preliminary stage in theory development.

Critical analysis of the current techniques utilised to measure ‘Quality Care’ resulted in the conclusion that pre-determined, quantitative tools are at best blunt instruments, producing potentially inadequate ordinal level data which provides equivocal indications of care quality. For the results of a quality assessment to be credible the measurement techniques need to be reliable, valid and sensitive, and sufficiently sophisticated to be able to reflect the complex and multiple dimensions and perspectives of the concept ‘Quality Care’. It is suggested that methodological difficulties originate from the theoretical deficiencies which are created in turn by conceptual ambiguity.

A conceptual model is presented as a means of clarifying the concept ‘Quality Care’, delineating the critical attributes and permitting the proposition and exploration of relationships between the elements (Walker and Avant, 1988). The model of ‘Quality Care’ was constructed from data generated inductively from a concept analysis of quality (Attree, 1993); it is important to recognise that the variables and the model are provisional, requiring verification and refinement through research. It was anticipated that achievement of the initial theoretical stages would form the basis for development of nursing theory and research, thus contributing to the construction of reliable and valid measures of ‘Quality Care’.

Conceptual models

Fawcett (1989) regards conceptual models as pre-theoretical structures, usually constructed to clarify abstract concepts and structure knowledge. Keck (1989) proposed that models aid theory development as they assist in the compilation of concepts necessary to represent the phenomena of interest and discover the relationships between them.

Challenged by the conceptual confusion surrounding ‘Quality Care’ and the dearth of reliable and valid measures of the concept, it seemed appropriate to attempt to develop a model of ‘Quality Care’. Construction of a model would assist in the clarification of this complex and abstract concept by:

1. identifying the variables defining ‘Quality Care’, 2. identifying the multiple dimensions and perspectives of ‘Quality Care’, 3. contributing to the construction of credible and acceptable measures which would

adequately represent the various dimensions and viewpoints, 4. permitting the exploration of postulated relationships between the elements of ‘Quality

Care’,

thus offering direction to nursing theory and research by the provision of a basis for the

A MODEL OF QUALITY CARE 15

structuring of nursing knowledge, thereby aiding the development of nursing practice, education and management.

The difficulties involved in constructing a conceptual model of a complex and multi- dimensional concept such as ‘Quality Care’ are acknowledged here; nevertheless the project was undertaken with the recognition that the proposed model may not be comprehensive. It was considered that an incomplete or imperfect model of quality care might nevertheless have value by raising the problem of lack of conceptual definition to the level of awareness and encourage discussion and debate.

Construction of a conceptual model of ‘Quality Care’

Construction of the conceptual model of ‘Quality Care’ will be described in three phases; firstly the elements of the model will be identified and profiled; secondly, the relationships between the variables will be postulated and finally a conceptual model of ‘Quality Care’ will be presented. Although the elements of the model are introduced as categories, they are not conceived as occurring uni-dimensionally or in isolation; the variables are envisioned collectively, functioning as a dynamic, integrated and interrelating set or group.

Elements qf the model

Attributes (criteria). Attributes (criteria) are the observable and quantifiable aspects which must be present for a valid characterisation and explanation of the concept. Walker and Avant (1988) regard the identification of the defining attributes of the concept of interest as an essential preliminary stage in the construction of a conceptual model. A content analysis of the literature (Attree, 1993) revealed the principal attributes defining ‘Quality Care’, which are outlined below.

Structure, Process and Outcome criteria. ‘Quality Care’ emerged from the concept analysis as a complex and multi-dimensional construct (Attree, 1993). The defining attributes identified from the literature analysis as characterising ‘Quality Care’ were classified using three dimensions. Donabedian’s Structure, Process and Outcome criteria were utilised to provide a unifying framework for the presentation of the attributes identified as criteria of ‘Quality Care’ (Donabedian, 1966). The defining attributes are presented by dimension in summary form as criteria lists in Tables l-3. These criteria lists and categories are unlikely to be exhaustive; they do however, provide an indication of the nature and complexity of the concept ‘Quality Care’. The criteria lists are deliberately left open to signify the incomplete state of knowledge in these domains, and also to indicate areas requiring further research and theory development.

The categories of criteria used to define quality may represent differing dimensions of a single element or factor comprising ‘Quality Care’. The criteria defining ‘Quality Care’ were classified simultaneously in three dimensions. Each cell in the theoretical structure may comprise structural, process and outcome criteria or dimensions of quality. That is ‘Quality Care’ can be categorised not only with reference to structural criteria, but also according to types of processes and categories of outcome. This notion is represented diagrammatically in Fig. 1.

An evaluation that focuses on one single aspect or dimension of ‘Quality Care’ produces an incomplete and fragmented uni-dimensional assessment of that construct. For the results

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Table 1. Structural criteria of ‘Quality Care’

Criteria type Examples

(a) Organisational variables (i) Hospital Goal/mission/philosophy, ethos.

Size: bed numbers, bed occupancy, throughput, activity level. Competitiveness and credibility. Resources/funding. Cost effectiveness. Excellence in management: structure and organisation, power,

authority, co-ordination, type of accountability, i.e. hierarchical vs professional.

Leadership, supervision. Shift length. Effective communication. Social relationships & support structures. Staff morale, satisfaction, turnover, absenteeism.

(ii) Unit/Practise setting

(b) Patient environment

(c) Service attributes

Concept of care/philosophy of nursing. Manpower: skill-mix; numbers, grades, competence; level of

education; professional development. Accountability, leadership & supervision.

Nurse assignment patterns. Patient care episodes; length of stay. Patient numbers, acuity/dependency. Resources: human, i.e. time to care, teach;

material, i.e. equipment; physical facilities.

Physical: buildings: type, maintenance and repair; hygiene, cleanliness.

Equipment, facilities, services. Social: atmosphere/climate/milieu.

Accessability, Equity. Relevance to need. Social acceptability. Comprehensiveness, Continuity, Coordination. Effectiveness, Efficiency and Economy.

of a quality assessment to be comprehensive measurement techniques are required to represent the complex and multiple dimensions of the concept ‘Quality Care’.

Perspectives. The literature analysis revealed five perspectives from which quality can be viewed (Attree, 1993). These perspectives were categorised as the Professional, incorporating the views of Medicine and Nursing; the Managerial perspective, including a Provider and Purchaser view; fourthly, a Patient/Client and lastly, a broader General Public/Societal view, and are depicted in Fig. 2. The principal features constituting each perspective will be outlined and related to the criteria used to represent that view of quality care.

The Professional view predominated in the literature; within this perspective two sub- groups emerged, Medicine and Nursing. The focus and essence of each view of ‘Quality Care’ varied according to their discipline. In Medicine the focus was upon the “classic medical outcomes”; described by Lohr (1988) as “the 5Ds”: Death, Disease, Disability, Discomfort, and Dissatisfaction. The first three of these outcome criteria are currently well represented in medical audit; the latter are notable by their absence. It is not yet apparent


Table 2. Process criteria of ‘Quality Care’

Criteria type Examples

(a) Care functions/processes Assessment. Planning. Intervention: physical and psycho-social care, patient education. Recording. Evaluation.

(b) Interpersonal processes

(c) Method of organising work

(d) Professional perspective

Effective communication. Manner and behaviour of care providers Therapeutic interaction. Involvement of patient and family. Provision of a supportive environment.

Effective coordination. Individualised. personalised care. Patient centred/primary vs task/routine. Involvement, partnership and participation in decision making and care

with patient and family.

Approach to, and philosophy of nursing. Attitudes, beliefs and values. Accountability. Therapeutic Nursing Functions: inclination and time to care. listen,

talk and teach.

(e) Professional practices Knowledgeable, proficient and technically competent. Sound clinical knowledge, skills and judgement.

(f) Personal characteristics Qualities: care; compassion; concern; empathic; integrity; humanism; kindness; respect of individual’s rights, dignity and individuality.

what criteria fundholding general practitioners and doctors involved in internal trading are using when negotiating contracts with service providers. In these situations the role of the professional and that of the provider or purchaser may be inconsistent, even incompatible; the dominant perspective will determine the type of criteria selected to define and evaluate quality in contracts for the service. It is postulated that Professions Allied to Medicine and Health Care, e.g. Occupational and Physical Therapy, Pathology, Social Work, etc., possess their own professional perspective on quality and situate their emphasis on different criteria to define the quality of their service.

In the professional sub-group Nursing, the focus was primarily upon the processes of care: assessment, planning and care delivery as well as interpersonal aspects of nursing practice. Parish (1986) depicted quality nursing using process criteria: commitment to holistic and individualised care, involvement of patients and family, provision of emotional support and comfort. The nurses in Jackson-Frankl’s (1990) study identified interpersonal aspects of quality care: time to spend with patients, listening, talking and teaching as determinants of quality care. These proposals correspond with the views of Kitson (1986) and with the patients interviewed by Taylor et al. (1991). Outcomes were also acknowledged by nurses as being correlates of quality care, examples suggested by Kitson (1986) include changes in health state, functioning or knowledge. Marek (1989) proposed additional categories of care outcomes: goal attainment; patient safety, satisfaction and wellbeing; physiological, psychological and functional status; and symptom control. Interestingly cost

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Table 3. Outcome criteria of ‘Quality Care’

Criteria type

(a) Health/wellness level

(b) Functional ability

(c) Patient satisfaction

(d) Resource utilisation/cost effectiveness/ efficiency

(e) Undesirable events

(f) Undesirable processes

Examples

Death, Disease, Disability, Discomfort and Dissatisfaction. Morbidity; Mortality; Survival rates. Control of illness. Low stress levels. Improvement/maintenance of health. Patient health knowledge. Problem resolution; Goal attainment. Rehabilitation; Symptom control. Peaceful death. Physiological, Psychological & Social-functioning. Self care ability, Motivation, Skill. Access; Availability of services. Communication. Complaints; Compliments. Co-ordination; Timing. Benefit vs harm; Quality of life. Effect for individual patients. Compliance. Patient return rate. Cost of correction/ repetition/compensation. Accidents and incidents: falls. Complications: contractures, nosocomial infections,

pressure sores. Iatrogenic diseases. Readmission, return to theatre. Patient self harm, Suicides. Post mortems, Untimely deaths. Medication and recording errors. Uncoordinated services. Unmanaged pain.

was classified by Marek as an outcome, although this is more commonly considered to be a structural criteria. Nurses included other variables to depict quality care which were classed as structural, including both human and material resources, adequate staffing, skill- mix and method of care delivery (Jackson-Frankl, 1990). Kitson (1986) included physical facilities and organisational variables in her structural attributes of quality nursing.

The perspective of the Provider/Supplier of care, that is a general management view emerged as the second most frequent view of quality care in the late 80s. The dominant issues in the Managerial view of quality are summarised by Pollitt (1988) as “virtuous 3Es”: Economy, Efficiency and Effectiveness. The emergence of this view can be associated with the rising cost of health care; as cost containment has become an increasingly important issue the health care manager’s focus has shifted further along this path, and can be summarised as the Purchaser/Payer’s perspective. The criteria used to evaluate quality care in these two related viewpoints are similar, and are summarised by Pfeffer and Coote (1991). Providers and Purchasers tend to focus principally on structural criteria; typically organisational variables, e.g. human and material resources, costs and environmental variables e.g. buildings. The ascendency of the Purchaser/Payer’s perspective has important ramifications; these two groups are responsible for contract negotiation, and the selection and execution of quality monitoring exercises. It is probable that the quality standards in contracts and the criteria used to measure quality will concentrate on inputs or structural criteria which represent the Managerial view of quality. This could explain the lack of

A MODEL OF QUALITY CARE

Structural criteria

ia

criteria Fig. 1, Dimensions of ‘Quality Care’.

Public / Society

A Patient / Client

Purchaser Provider

Management

Fig. 2. Perspectives on ‘Quality Care’.

endorsement and disquiet expressed by some professionals when faced with quality measurement and management tools which differ in their perspective and interpretation of quality.

The Consumer’s perspective, identified by Pfeffer and Coote (1991) and Taylor et al. (1991) began to emerge in the late 80s and early 90s. It was not clear from the literature who constitutes ‘the consumer’; formerly the patient/client was regarded in this role. Since the NHS reforms, however, a subtle yet vital change has occurred. Purchasers of health care are now considered to be the customers as they have the power and authority to commission services. Within the Purchasers perspective the patient/client is seen as a throughput or output rather than as the consumer. Keighley (1989) asserts that it is vital

20 M. ATTREE

to understand who the customer is and what their needs are. Problems in the selection of criteria with which to judge quality of care could arise from the lack of clarity regarding who is the consumer because the two groups, purchasers and patients, utilise different criteria.

The perspective of the Patient/Client was the least commonly represented in the literature. Patients, according to Pfeffer and Coote (1991) focus upon “how they experience output”, a mixture of process and outcome quality criteria. Patients in Taylor et al.‘s (1991) study considered that clinical competence was important, in Van Essen’s sample clinical competence was rated most highly by patients (Van Essen, 1991). Thompson (1983) found that patient satisfaction was related to the content of care, i.e. what is done and how, whilst dissatisfaction was related to the context of care, i.e. buildings and facilities, which are structural criteria. It is interesting to note that these criteria are not commonly assumed to be the focus of patients, whose primary interest is considered to be the effects or outcomes of care, with some regard for structural criteria (Pfeffer and Coote, 1991).

Contradictory positions were expressed in the literature without regard to the dissonance. Managers and Professionals both acknowledged that the patient’s view was important, however if that opinion differed from their own perspective the professional’s view predominated (Holloway and Mobbs, 1992). The patient’s view of care quality was perceived as subjective and therefore subordinate to the Professional’s perspective (Wright, 1987). This conclusion appeared to be justified on the grounds that patients are uninformed and incapable of impartial judgement.

The Patient/Client’s perspective was expanded to form a related, but broader viewpoint. The Public/Society position incorporates the views of the general public and pressure groups as well as potential service users. Maxwell’s criteria: accessability; relevance to need; effectiveness; equity; acceptability; efficiency and economy are used to reflect the wider dimensions of quality health care (Maxwell, 1984). Organisations such as Community Health Councils and patients’ groups have attempted to realise the patient’s right to “choice and voice” (Pfeffer and Coote, 1991) in health services. The views of these groups are now actively being sought following encouragement from the government via HMSO The Citizen’s and Patient’s Charter (1991) initiatives.

The dominant perspective appears to have altered over time; the Professional view was the most frequently represented in the literature of the 70s and SOS, with the Provider following second. In America by the late 80s the Purchaser position was becoming pre- dominant; this trend is becoming apparent in the British health system as the government attempts to control the increasing cost of health and social care. The contemporary managerial view of quality emphasises consumer satisfaction and meeting customer expectations (Crosby, 1984); ironically within the current NHS business culture it is the purchaser that is considered the consumer rather than the patient, client or potential service users. Maxwell’s (1984) dimensions of quality health care may provide the criteria which correlate the various perspectives.

If a comprehensive evaluation of ‘Quality Care’ is to be achieved, in accordance with the recommendations of the Audit Commission (1994), the attributes used to define quality in each perspective, and the relative prominence given to the criteria require urgent identification.

Context/ Environment. The concept ‘Quality Care’ does not exist in isolation; it is context- specific and influenced by various environmental factors, both internal and external to the


health care system. Variables identified as Context or Environment factors emerging from the setting/situation were classified according to their scope, as Macro, Micro or Global. Contextual/Environmental factors are dynamic and fluctuate according to the prevailing conditions both within and surrounding the system within which the health care sub-system functions.

Variables within the Macro health care system context/environment identified as affecting ‘Quality Care’ were: the prevailing Macro-Economic Climate, i.e. National, Political, Econ- omic and Social Policies; the nature of the Infrastructure; the type of Public Accountability as well as Societal Expectations. Cooke (1992) described quality as “a social construct which is shaped by our values and expectations about it”. Individual and societal expectations about the quality of a service are influenced by the context of that service; the quality expected of a meal from a fast food outlet would be different from that anticipated from a five-star restaurant. McFarlane (1989) suggested that quality measurement could be compared to hotel rating systems - the grade representing the prospective standard of excellence.

Geographical, social and organisational aspects reflecting the Local or Micro context/environment emerged as factors affecting the quality of health care services. Attributes classified as Local/Micro variables encompassed the geographical and social construction of the neighbourhood, district and region as well as including the broader anthropological concepts of Community and Society. Maxwell’s (1984) criteria: Relevance to Local need; Equality of Access; Availability and Acceptability were also categorised as Micro-locality variables of ‘Quality Care’. Other elements within the micro-organisational environment such as the structure and culture of the organisation; the degree of de-centralisation of service planning and type of management: functional vs general, were identified as factors influencing quality care. Additional variables included the type of provision: general vs specialist; local vs regional; acute vs continuing or long term; and Primary vs Secondary or Community Care.

Factors relating to the Global situation, that is the wider economic and social and situation and the level of development of the country/state were also identified as factors affecting the quality of service provision. In developed countries of the Western World the health state and level of health care provision experienced and expected is usually more comprehensive and superior to services in underdeveloped countries. The criteria used to judge the quality of health care services received is directly influenced by expectations and past experiences of care provision in the locality.

Time/Era. Additional contextual influences affecting ‘Quality Care’ were categorised here as Time/Era variables. These factors summarise the prevailing ideologies of the era which are transposed into the organisational culture of the health care system and become the principal criteria determining quality. Pedler et al. (1991) assert that every organisation is influenced by, and must fit into their era in order to remain a viable business concern.

From the literature periods of Time/Eras were identified which were categorised by the way quality was interpreted, characterised and evaluated. Former times were identified as Pre-Industrial/Craftsman, Industrial/Manufacturing, Managerial and Service Eras. The Craftsman Era was characterised by individual expertise and the creation of high quality wares or labour; quality was individually defined by the craftsman who inspected and assured his own work. This personal responsibility for quality prevails currently through the practice of internal professional/expert audit. Within the Industrial/Manufacturing Era

22 M. ATTREE

fitness for purpose and conformance to standards were utilised to define and measure quality; detection of defects and quality control were dominant principles. This era can be recognised in health care, and in particular nursing, in the 1980s when standard setting was the customary method of defining and evaluating quality.

Quality in the Managerial Era can be characterised in terms of organisational factors eg resources or inputs which affect productivity or output; the primary organisational motive is market advantage and profit. The dominant issues of this era can be summarised as efficiency and effectiveness, and quality assurance; these issues have become the tenets of the current era of health care quality. Post-Industrial Service organisations are characterised by their interest in the provision of services or functions as opposed to production. In Service Industries, meeting customer requirements and consumer satisfaction define quality and become the principal interests; quality of service provision is their objective. Human Service Organisations-Health and Social/Welfare Services are usually distinguished from other service industries by their concern with the provision of services according to need rather than a profit-making motive.

In Britain the current time could be characterised as the Era of Business/Free Enterprise or Market Forces, and regarded as an extension of the Managerial Era. In the latest NHS reforms the organisational structure and culture have been changed to reflect a predominantly commercial or ‘market’ ideology, where health service are seen as com- modities to be bought and sold. LeGrand and Bartlett (1992) describe this as a Market Economy or ‘quasi-market’. The dominant principles of the Business/Market Era are competition; cost effectiveness/containment/improvement and value for money; the cor- porate objective being financial viability and survival. Prevailing British National Health Service Policies appear to be striving to combine the ideologies of the Managerial and Service Eras; how feasible this endeavour is remains to be seen. The rights of contemporary service users to ‘choice and voice’ and a prescribed standard of service were made explicit in The Citizen’s and Patient’s Charter (199 1) initiatives. Currently Health Service organisations appear to pay greater regard to the commercial tenets of the Management Era with limited regard being paid to the human service ethic.

The principal features characterising each Era are summarised in Table 4 ; these categories together with Contextual/Environmental factors affecting ‘Quality Care’ are situated on the criteria list (Table 5 ).

Relationships between variables/ elements

Once the defining variables have been identified the relationship between them can be postulated (Walker and Avant, 1988). The defining attributes of ‘Quality Care’ induced from the concept analysis were identified and presented as the elements of the model. The proposed relationships between the attributes/criteria of quality care, summarised in Table 1 and Table 2 and Table 3 and the perspectives from which quality care can be viewed (Fig. 2) are presented in Table 6, and represented diagrammatically in Fig. 3.

When mapped against each other no single criterion/attribute was identified as common to each perspective. Correlation of criteria between perspectives was evident to some extent on the attributes Cost Effectiveness, Resource Utilisation, and Satisfaction with Service. Where these criteria corresponded, variations of emphasis on different dimensions, rather than substance, were recognised. In the Managerial perspective Cost Effectiveness and Resource Utilisation were fundamental or central criteria; greater significance was placed


Table 4. Eras of quality

Era: Ideology

Pre-industrial/Craftsman Expert Professional

Industrial/Manufacturing Business/Commercial

Managerial Operational Performance

Effectiveness and Efficiency,

Service Customer requirements and satisfaction

Current British Health Service: “Market Forces” Market principles

“Free Enterprise” Value for money

Organisational Goal/Motive

Creation of high quality goodsjabour

Production of marketable goods

Market advantage,

Financial Viability and Profitability

Meeting contractual requirements

Conformance to standards Cost vs Benefit

Provision of Service Meeting need/requirement

Market Position

Financial Viability and Survival

Criteria determining and Quality Measurement Method

Individual standards

Quality control by individual inspection

Fitness for purpose and conformance to standards;

Quality control Detection of defects

Quality Assurance

Cost Effectiveness and Efficiency

Meeting prescribed service standards

Quality Assurance

on the structural and outcome variables, i.e. cost and benefit. In the Professional, Patient and Public/Society perspectives the process and outcome dimensions of these criteria were emphasised as most important, i.e. the effect of care in relation to health need.

The criterion Resource Utilisation comprised a variety of factors; Human Resources/ Workforce issues, notably staff skill-mix ratios, competence/expertise were identified as common attributes. These factors were considered and viewed with different emphasis by the various perspectives. Managers accentuated the structural aspects of this criteria, i.e. the cost of staffing. The Professionals, Patients and Public were more concerned with adequate numbers and appropriate knowledge, skills and competence; work practices were also important attributes emphasised by these groups. Patients and Public highlighted different, but related, dimensions of this criterion; for them staff attitudes and behaviour were emphasised as very important.

Satisfaction with Service also emerged as a common, but ambivalent criterion; different groups being inclined to emphasise different aspects of it. Managers considered that meeting service agreements, that is activity level and cost (structural aspects) constituted a sat- isfactory service. Professionals, Patients and Public focused on the both the process and outcome dimensions of this criteria, emphasising care functions and content as well the result. The lack of agreement identified earlier, as to who constitutes the consumer, the purchaser or the patient, may cause difficulties if this criterion is to be used as a unifying or collective criteria of care quality.

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Table 5. Criteria list of variables affecting quality of care

Perspectives 1

Defining attributes and dimensions

1

Managerial: Provider

Purchaser

STRUCTURAL Cost effectiveness Environment attributes Organisational variables Resource utilisation Service attributes Workforce: staffing & skill-mix

Professional: Nursing

Medicine

PROCESS Care processes: assessment, planning, etc. Care roles/functions Interpersonal processes Method of organising work Personal characteristics Professional competence

and work practices

Patient/client

Public/Society

OUTCOME Health/wellness level Functional ability Patient satisfaction Undesirable events & processes

Context/environment 1

CONTEXT Macro-economic climate National policies:

political, fiscal and social

Infra-structure Public

accountability Societal expectations

LOCALITY/ PLACE Socio-economic, political

& geographical location Relevance to local need Equality of access Availability Acceptability Micro-organisational

structure & culture Type of service provision

ERA/TIME Organisational ideology/culture Organisational goal

e.g. financial viability, cost effectiveness

Method of defining and measuring quality

It is postulated that a single criterion which could function as a composite indicator of ‘Quality Care’ does not exist. In order to accomplish a comprehensive evaluation of ‘Quality Care’ multi-faceted and composite measurement techniques are required com- bining both quantitative and qualitative paradigms.

Construction of a conceptual model

The perspectives, defining attributes/criteria and contextual/environmental factors identified as elements of ‘Quality Care’ were synthesised to produce a criteria list (Table 5). The function of a criteria list is to make the principal elements of a concept explicit. The criteria are listed in alphabetical order in Table 5 and do not signify their magnitude, importance or strength. The criteria lists are deliberately left open-ended to signify the incomplete state of knowledge in these domains. Although the criteria are presented as a list they are not regarded as isolated uni-dimensional elements, but as integrated and dynamic components of quality care. Criteria lists and maps are preparatory stages in the development of conceptual models; criteria maps provide a means of situating the postulated relationships, sequence and association between the attributes of a concept (Chinn and Jacobs, 1987).

Once the elements of ‘Quality Care’ had been identified a conceptual model of ‘Quality


Table 6. Perspectives correlated with criteria

Managerial Provider & Purchaser

Effectiveness, Efficiency & Economy

Resource utilisation Cost effectiveness Human & material

resources: Staffing & skill-mix Environment: buildings &

facilities Quality control &

management

Nursing Medicine

Care processes and functions Interpersonal processes Professional competence Health & wellbeing Functional status Adequate staffing & skill-mix Goal achievement; Patient satisfaction

Clinical outcomes:- Death, Disease, Disability, Discomfort Dissatisfaction. Professional expertise

PATIENT/CLIENT “How they experience output”:-

process and outcome criteria Interpersonal processes Satisfaction with care processes, outcomes

& contexts Health and functional status; wellbeing, need satisfaction & meeting expectations Clinical competence of staff Staff attitudes Care environment

PUBLIC/SOCIETY Access; Availability; Acceptability; Equity;

Relevance to need; Need satisfaction & meeting expectations Responsiveness to need Service credibility

Public / Society

A Patient / Client

Kev Purchaser Provider S - Structural

P - Process Management 0 - Outcome

Criteria Fig. 3. Relationships between perspectives and criteria.

26 hf. ATTREE

Contextual variables

Mi - Micro Ma - Macro Glo - Global

0 - Outcome

Criteria

Fig. 4. Conceptual model of ‘Quality Care’.

Care’ could be constructed. The model was conceived within an open systems framework as this provided a format which acknowledged the complexities of ‘Quality Care’. The defining attributes, previously identified through content analysis (Attree, 1993) i.e. structural, process and outcome criteria are subsumed into the input, throughput and output elements of Systems Theory. An open systems framework offered a structure which allowed for the consideration of the inter-relationship and inter-dependence of the variables comprising ‘Quality Care’. Using a systems model also enabled a dynamic approach to the representation of the elements encompassed within the concept ‘Quality Care’, allowing them to be considered in context, time and place; as well as in relation to associated concepts, emphasised by Rodgers (1989) as being vital for ambiguous concepts like ‘Quality Care’. The adoption of a systems framework would also permit the generation and testing of hypotheses arising from the proposed theory enabling the conceptual framework to be empirically verified.

The proposed conceptual model of ‘Quality Care’, presented as Fig. 4, should be regarded as provisional. The conceptual model was constructed from data generated inductively from the literature reviewed and analysed (Attree, 1993); thus this model may not include all conceivable attributes or perspectives of quality care. For this reason the criteria lists were intentionally left open-ended to symbolise the incomplete nature of current knowledge. The variables, their relationships and the proposed model require verification, development and refinement through research.

Summary and conclusions

This paper proposed a conceptual model of ‘Quality Care’ constructed from data generated inductively from an analysis of the concept ‘Quality’. The model was conceived in order to facilitate the clarification of the multiple dimensions and perspectives of the concept ‘Quality Care’ by assisting the investigation of the elements of quality care and their relationships. It was also anticipated that achievement of these initial theoretical stages


would form the basis for development of nursing theory and research. For the development of a theory of quality it is crucial that there is some level of consensus as to what constitutes quality and how it can be measured to provide empirical reference points.

The proposed model adopted a systems framework as it provided a format which acknowledged the complexities of ‘Quality Care’, and offered a structure which allowed for consideration of the inter-relationship and inter-dependence of the various elements comprising ‘Quality Care’. Using a systems model also enabled a dynamic approach to the representation of the elements encompassed within the concept of ‘Quality Care’, i.e. perspectives, defining attributes, dimensions and contextual/environmental factors, allowing them to be considered in context, time and place.

It is important to recognise that this conceptual model is provisional, reflecting the incomplete nature of current understanding of the concept ‘Quality’. In order to test the proposed model the criteria identified need to be validated and their inter-relationships tested empirically; the next phase of this study aims to verify the elements of ‘Quality Care’ and investigate their correlation through research.

References

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(Received 20 March 1995; acceptedfor publication 27 March 1995)

towards a conceptual model of ‘quality care’

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