Elsevier

Clinica Chimica Acta

Volume 333, Issue 2, 15 July 2003, Pages 115-124
Clinica Chimica Acta

Measuring against clinical standards

https://doi.org/10.1016/S0009-8981(03)00175-XGet rights and content

Abstract

Systematic improvement of health services requires the objective measurement of people, practices and organisations against valid and explicit standards in order to identify and implement appropriate change.

Effective quality systems must embrace a wide range of definitions of quality, and a similar variety of approaches to defining, measuring and improving. Clinical performance may be examined from three professional viewpoints—Clinical competence: assessment of individual practitioners against explicit criteria to recognise achievement and to promote continuing development. Traditional mechanisms of training, registration and accreditation enable clinicians to reach career grades but responsibility for subsequent support is often unclear between employers, professions and registering bodies. Clinical practice: assessment of actual clinical process and outcomes against research-based “best practice” to identify and reduce variation. Peer review, clinical audit and confidential enquiries are examples of this approach, which may involve single or multiple professional groups and their interface with management. Service accreditation: systems to assess health care organisations against published standards in order to encourage best management practice. These are usually run on a regional or national basis and, though sensitive to expectations of patients, managers, clinicians, paying agencies and government, they are usually managed by an impartial but authoritative organisation.

Section snippets

Standards and measurement in health care

Traditionally, health services used to be measured in terms of the input or the resources they use (Fig. 1). The impact of the service or of a given clinical practice on the individual or the population was an implicit assumption, not only because such outcomes were hard to measure, but also because the resources used were easily counted and had the most immediate political impact.

However, a growing interest in clinical outcome seeks to differentiate between ‘outputs’ in terms of volume as

External

Procedures for the licensing of doctors, dentists and nurses are prescribed by law in most countries and are delegated to an accountable body (often at the level of state or province) which defines standards and maintains a professional register. Standards for periodic relicensing and for other professions are more variable.

Responsibility for defining standards of undergraduate and postgraduate training are variously shared between national coordinating bodies and professional and academic

Measuring clinical practice

Concepts of clinical effectiveness and evidence-based medicine have become the heart of quality in clinical practice, for a variety of reasons including:

  • •

    much evidence has accumulated of unacceptable variations in clinical practices and results among doctors who are treating similar patients in similar circumstances

  • •

    adding together the results of existing biomedical research (“meta-analysis”) has greatly increased the power to define effective clinical practice

  • •

    few day to day clinical practices

Measuring service delivery

Much of the early development of quality in health care focused on improving the performance of individual personnel, teams and functions. Attention has now shifted towards their integration within and between organisations, largely because:

  • •

    the tradition of doctor-led patient care is moving towards multidisciplinary team working

  • •

    competent teams cannot excel without the support of an effective organisation

  • •

    many opportunities for improvement are between rather than within teams, functions and

Conclusion

There are many areas of health care where there is no RCT-based evidence that compliance with clinical standards improves individual or population health outcomes. There are also many areas in which evidence based on experience is available but it is not systematically analysed, translated into guidelines, implemented and monitored. Learning barriers exist between departments, institutions, regions, specialties and countries.

Research evidence and meta-analysis of health care technology is now

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