dimensions of quality revisited: from thought action · quality in health care 1992;1:171-177...

Quality in Health Care 1992;1:171-177

Dimensions of quality revisited: from thought to

action

Robert J Maxwell

It is some years since, in an article reviewingthe state of quality assurance in Britain,' Iargued that quality in health care ismultidimensional. This was not a new

proposition. Donabedian, for example, hadrecognised that patient satisfaction can oftendiverge from technical efficiency as perceivedby the expert provider.2 As used to be said ofone energetic surgeon, "His patients loved himand they died young." The two views ofquality are clearly not identical: the methodsfor measuring them and the people best placedto judge them differ.Although Donabedian and others had

recognised multidimensionality, the dimen-sions of quality I described were, I think, a

genuine step forward in describing andexplaining six facets of health care quality (box1). It is gratifying that they struck a chord andthat they seem to have been useful, bothpractically and conceptually, at severaldifferent levels in the system. However, theyare obviously not the last word on so complexand important a subject. The purpose of thisarticle therefore is, firstly, to reflect on some ofthe ways in which the dimensions have beenused since they were proposed (there may wellbe many other examples, but those given hereare at least illustrative); then to revisit theconcepts underlying them; and, finally, toargue that we must not let the search for

Box 1 Six dimensions of quality

quality become too intellectual, purist, andstatic: "the letter killeth, but the spirit givethlife."3 Mark Twain remarked about the Britishweather that everyone in Britain talked aboutit, but nobody did anything about it. Let notthe same be said of quality in British healthcare. After all, in recent years we even seem tohave done something about the weather.

Using the dimensionsEAST ANGLIAN EXAMPLE

East Anglian has some claims to the title offlagship region in its early, bold attempts toexplore the meaning of a managed market. Ittook the view that the NHS reforms were notan end in themselves but a means to an end.The end had to be, in some terms, healthoutcome. The region adopted the sixdimensions of quality, slightly retitled to formthe mnemonic EEEAAR, to express thecorporate values underlying its definitions ofhealth outcome. These values have been usedconsistently in East Anglian region for the pastfew years to underpin performance contractsbetween districts and region and betweenproviders and purchasers and to tacklestrategic issues (box 2). Hence, the explicitdefinition of corporate values helps to remindmanagement and others that the drive toefficiency should not be at the expense ofequity or the pursuit of accessibility (forexample, reduced waiting lists and waitingtimes) at the cost of appropriateness (forexample, high standards of emergency care

and chronic care). It might be difficult todemonstrate the precise impact of thedimensions on quality of health care in theregion. What they seem to have done is toprovide a shared framework for discussionamong "insiders" (managers and professionalsat various levels and members of authoritiesand trusts) about intentions andperformance.

HEALTH ABACUS EXAMPLE

The Health Abacus (box 3), a joint venturebetween South West Thames Regional HealthAuthority and the Office for PublicManagement, has been developed as a

simulation of illustrative purchasing dilemmasand decisions for use by, for example, districthealth authority officers and members or

district and family health services authoritiesthat want to explore the complementarity ofwhat they are doing.The basic point behind the simulation is

that decisions are about policy trade offs - not

only, as Sir George Godber succinctly put it,

King's Fund, LondonW2 4HTRobert J Maxwell,secretary and chiefexecutive

Questions that help to define and expand the label "quality"Effectiveness: Is the treatment given the best available in a technical

sense, according to those best equipped to judge? What istheir evidence? What is the overall result of the treatment?

Acceptability: How humanely and considerately is this treatment/servicedelivered? What does the patient think of it? What would/does an observant third party think of it ("How would I feelif it were my nearest and dearest?") What is the setting like?Are privacy and confidentiality safeguarded?

Efficiency: Is the output maximised for a given input or (conversely) isthe input minimised for a given level of output? How doesthe unit cost compare with the unit cost elsewhere for thesame treatment/service?

Access: Can people get this treatment/service when they need it?Are there any identifiable barriers to service - for example,distance, inability to pay, waiting lists, and waiting times -or straightforward breakdowns in supply?

Equity: Is this patient or group of patients being fairly treatedrelative to others? Are there any identifiable failings inequity - for example, are some people being dealt with lessfavourably or less appropriately in their own eyes thanothers?

Relevance: Is the overall pattern and balance of services the best thatcould be achieved, taking account of the needs and wants ofthe population as a whole?

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"that an investment in some part of the serviceis at the expense of an effort given tosomething else, which others may think moredeserving"" but also about trade offs betweenunderlying values. The most illuminating partof the abacus simulations is not thesimulations themselves, fun as these are. It isin the debriefings afterwards, when theparticipants are challenged to reflect on (forexample) what part equity or appropriatenesshas played in their simulated decision, versusthe pursuit of greater efficiency, or what theyconsidered to be acceptable to the public orthe politicians. For this purpose the policytrade offs are deemed to be between the valuesrepresented by the six dimensions. By values,I mean our underlying assumptions aboutwhat matters in health care. Hence the Abacus

One of the first hospitals whose existence was threatened in East Anglianafter the introduction of the internal market was Mundesley Hospital, asmall, isolated, post-acute inpatient rehabilitation unit of 38 beds, whichwas used by patients from all over the region. Its closure had beenthreatened for many years, a decision which the managing health authority(Norwich) had deferred, given the strength of local feeling.Once the internal market was introduced, this issue became the

responsibility of several purchasing authorities, each responsible fordetermining the health needs of its respective population and placingcontracts to meet them. Each authority was expected to address the issueof the kind of rehabilitation service it wished to purchase as a potentialreplacement for Mundesley Hospital.

In doing this each sought to apply the regional values (effectiveness,efficiency, equity, access, appropriateness, and responsiveness) to derive asolution which represented the best compromise or "trade off" betweenthose values. For example, in framing a specification for an alternativepattern of service provision, Norwich Health Authority sought a servicewhich was:* Effective - care and treatment programmes would show evidence ofreduced functional impairment, based on a system of clinical audit

* Efficient - there would be a reduction in acute hospital stay andincreased throughput

* Accessible - within about 5 km (three miles) of the Norwich ring road,proximity to the major sources of referral being advantageous but notessential

* Appropriate - utilising an "individual patient programme" approach* Responsive - ensuring progression to graduated self care and day care,

as appropriate, and utilising a nationally accepted patient satisfactionmethodology

* Equitable - ensuring that people with identical needs receive the samestandard of care regardless of where in the region they lived or weretreated.

Using the dimensions framework helped to clarify the underlying conflictbetween values as they applied in this case, particularly betweeneffectiveness on the one hand and accessibility and responsiveness on theother. Unsurprisingly, the preferred solution for Norwich based on theapplication of these values was a relocated, consultant led, rehabilitationcentre supported by a specialist community team.

In another authority in the region, meanwhile, a community providerunit undertook a similar analysis of the same issues, underpinned by anexplicit use of the regional values, to prepare a business plan, arguing itscase for establishing an entirely community based approach associatedwith its well developed "hospital at home" programme. This was acceptedas the best available alternative to use of the remote and inappropriateMundesley Hospital.A satisfactory position has been reached whereby Mundesley Hospital

can now be closed as a genuinely redundant institution, based on a seriesof explicit purchaser and provider analyses expressed in terms of theregional values. The result has not been to create a series of identicalalternatives to Mundesley Hospital but a range of different solutions fordifferent authorities, each based on a particular purchaser's interpretationof the regional values in the context of what constitutes a goodrehabilitation service.

is a metaphor. What the players (in real life,members of a health authority) are doing is

Developed by Sian Griffiths, director of publichealth for South West Thames region, andLaurie McMahon from the Office for PublicManagement in 1991, the Health Abacus wasdesigned to help members of that new regionto understand better purchasing for health gainat a local level.

Its name was chosen to reflect the reality ofpurchasing, in that it was not about achievingsimple health targets but much more abouthaving to make policy trade offs. These may bebetween competing health needs, or alternativeservice configurations, or between criteria forimprovements in health services, such asefficiency and access. It may also entail tradeoffs between health improvements and a wholerange of "constraining" factors such as publicpreferences and the influence of professionalsat provider level. Moving the beads on thewires of an abacus seemed to fit the way inwhich authorities would have to balance thelevel of achievement they require on each oftheir criteria for health gain.The success of the prototype prompted the

region to develop it for districts and familyhealth services authorities, during which itattracted interest outside. Dr Griffithsexplained, "We were using Health Abacusmaterial for national conferences where it wasseen by people from the NHS ManagementExecutive. They were impressed enough tofund its development as a free standing packthat could be used by other health authoritiesto develop their purchasing skills."The pack provides the basis for running a

training day with a simulation of specificpurchasing dilemmas and decisions. The startof the day is devoted to setting the managerialand public health contexts in which healthauthorities must work, which provides anopportunity for members to clarify their rolesas purchasers and to understand the dynamicsof their relationships with regulators, healthand social care providers and generalpractitioners, and the public.

Participants then work to "sophisticate" theorthodox model of health policy making inwhich health needs are balanced againstavailable resources. Once a much more realisticunderstanding of purchasing process, with allits dilemmas and trade offs has beenestablished, the simulation stage begins.The rules that govern the play are extremely

simple since participants maintain their realboard member roles and only the policy issuesare simulated. These are highly realistic andhave been designed to exploit theorganisational and public health trade offswithin the "abacus" of health gain, and ifselected from the portfolio with care they canbe used to explore real life dilemmas for thedistrict or family health services authority.For Laurie McMahon the Health Abacus is

not a game: "It doesn't produce winners orlosers and it is not a puzzle that has a rightanswer. People do enjoy the exercise and thesimulation is good fun, but they are in theirreal roles and are using their real values toinform their judgements about how to achievemaximum health gain. There is some seriouslearning to be derived from that."

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Dimensions of quality revisited

Proposed Audit Commission focus

Technicaleffectivenessand useracceptability

Source: Adapted from Audit Commission'

Conceptual framework for quality

gaining insight into the nature of the trade offsbetween, for example, equity and efficiency or,

say, acceptability and access.

The similarity with the East Anglianexample is that both are concerned with core

values. The difference is that Health Abacus isessentially developmental, encouraging peopleto be more reflective in a training situation.The East Anglian example is in a sense more

prescriptive in that it uses the six dimensionsto make the basis of regional strategyexplicit.

US UKEffectiveness

Acceptability

Efficiency

Access

Equity

Relevance

Commentsi-++ ++ For many technical procedures the US system

is ahead in ingenuity world wide. The UKsystem is more conservative, less wellequipped, and rather less "hooked" on

technology- sometimes wiselyi-++ + For most US citizens American health care is

well ahead of Britain on the consumer

dimension - for example, explanation,amenities

+ ++ Both systems are inefficient in different ways.The US system can be very efficient at theinstitutional level but extremely extravagant atthe system level whereas the opposite is true inthe UK system, which costs less than half theUS system per head

++ ++ The systems have different virtues and vices.The vice in the US system is the barrier ofpayment, affecting the uninsured. That in theUK is waiting for elective treatment and forsome other services (for example, geriatricassessment)

o ++ To non-Americans the US system seems

obscenely inequitable, with some 35 millionuninsured, who may face financial ruin if theyneed expensive medical care

+ ++ Though the US system has a high level ofprovision and is sensitive to demand, it isgrossly skewed towards acute care. The UKsystem is more balanced and is stronger inprimary and chronic care

Box 4 Comparison of quality of health care systems in United States and UnitedKingdom

AUDIT COMMISSION EXAMPLE

The Audit Commission has considered the sixdimensions, along with various otherreferences on quality (both in health care andin other sectors), in deciding where to positionits own work. It was inclined at one stage to

merge the dimensions of access and equity on

the grounds that they were close enough not tobe differentiated. I understand this argument,but I am not convinced by it- or at least notyet. This is a conceptual question to which Iwill return later. The main point, however, isthat the commission found the idea ofmultidimensionality convincing and useful. Itmight well have taken a narrow view of its roleas being to ensure that the NHS is efficient inconverting inputs to outputs and hence inproducing as many units of service as possiblefor a given public expenditure allocation.What it is doing instead is to concentrate itsown work on technical quality (my effective-ness dimension) and on patients' views (theacceptability dimension) while recognisingthat this is only part of a fuller quality map.

Because its concern is mainly with providers ithas decided that these two dimensions are theones to emphasise, along with efficiency. It ismaking the (bold) assumption that purchaserswill take care of the other quality dimensionsand is making this assumption explicit,showing how its work is expected to fit into a

larger conceptual framework (figure). Indeedat a conceptual level this nicely illustrates thevalue of using several separate dimensions todecide where to concentrate efforts to improvequality.

EXAMPLES COMPARING INTERNATIONAL OR

INTER-AREA PERFORMANCE

In my role at the King's Fund College I oftenfind myself having to talk to overseas visitorsat the start, or the end, of a visit to studyvarious aspects of the NHS. I find the dim-ensions useful in arguing that, like a curate'segg, the NHS is good in parts. Relative to theUnited States, for example (box 4), our

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arrangements are strong on equity and arevery low cost: our balance of services betweenprimary and other levels of service is good, andwe use our limited resources more efficientlyand more relevantly. But relative to mostAmericans, a British citizen using the NHSreceives a less consumer friendly service (theacceptability dimension). Americans living inBritain are likely to be struck by the neglectedand dirty state of NHS premises and by thelack of time taken discussing with them whatis going on. On the other hand, if the visitorscome from central Europe they will certainlybe less critical of these aspects. Theynevertheless need to have a framework inmind for comparing what they see with whatthey know in their own nation's services. Onthe whole, what people should gain frominternational experience is not "solutions" toproblems, since few are transferable and evenfewer are panaceas. Rather, it is a deeperunderstanding of the strengths and weaknessesof their own system, seen within a frameworkof relevant values. That ought to make us allless complacent and, if we are genuinely benton the pursuit of excellence, clearer aboutwhat to try to change and what to preserve.

Conceptually, of course, this applies just asmuch to comparisons between areas (orindeed between institutions) as to inter-national comparisons. As an illustration, box 5attempts to summarise the relative strengthsand weaknesses of London's health servicesand to show how the recommendations of the

King's Fund's London Commission willprovide a balanced strategy for reform.

Revisiting the conceptsThe definition of the six dimensions (box 1)and precisely how many dimensions thereought to be are far less important than theacceptance of multidimensionality, the flavourof the dimensions, and of the policy trade offsamong them. As remarked earlier, the AuditCommission seems likely to have eliminatedone dimension by amalgamating access andequity, on the grounds that most inequities areabout uneven access. For now, I prefer to keepboth dimensions because there can also beother inequities that have nothing to do withaccess. For example, advocates for ethnicminorities argue with some justice that there isa systematic, if largely unconscious, bias inmost public services against minorities thatgoes far beyond inequality of access. It hasseemed to me, therefore, that we should retainthe distinction between access and equity,despite the considerable overlap between thetwo.

In a technical sense this can be presented asan argument about orthogonality - literally thestate of being rectangular. It is used moreloosely by architectural planners to determinewhether the dimensions selected to definespatial relationships are as independent of oneanother as possible. In deciding how to clusterhospital departments, for example, architectshave to take account not only of frequency of

StrengthsEffectiveness As large a supply of

professional skills in acutemedicine and nursing, etc, asanywhere in the world

Acceptability Loyalty to particularinstitutions and departments,based on performance forindividual patients

Efficiency Some very efficient units

Access Excellent access to specialistservices

Equity

Relevance

* Recommendations:

WeaknessesPrimary and chronic care.Many acute units too smalland too fragmented

Few mechanisms forcommunity involvement andlocal accountability. Still atradition of "noblesse oblige"High costs inevitable inLondon. Many units toosmall and fragmentedPoor access (for manypeople) to primary care andcommunity based chroniccare. Limited hospital accessfo routine conditionsInequity between inner andouter LondonGross imbalance of servicesrelative to need.Overinvestment in acute careand underinvestment inprimary care and communitybased care for chronicconditions

Recommendations(1) (3)

(2) (4)

Londoners to beinvolved in their owncare

(2) (3) (4)

(1) (2) (3)

(2)

(1) (2) (3)

(1) Strengthen primary care, starting with various experiments(2) Reduce numbers of general acute hospitals and their numbers of beds and increase their

outpatient care(3) Establish more and better community based care for chronic conditions(4) Concentrate tertiary referrals, postgraduate education, and research in four main groupings linked

to the main science schools of London University (Imperial College, University College, King'sCollege, Queen Mary College/Westfield)

Box 5 Summary of strengths and weaknesses of health services in London and King's Fund London Commission'srecommendations for reform

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communication between one department andanother but also of several other factors. Inother words, the problem is multidimensional.To avoid "double counting" between differentdimensions they need to be as independent(that is, uncorrelated) as possible. The same isobviously true of selecting and weightingindices of deprivation, as in the Jarman index.6By analogy, the more distinct from oneanother are the quality dimensions that weidentify, the more complete and balanced theprofile of quality that they will give. Indeed,correlation is actively dangerous if one is tryingin the end to derive a comprehensive systemfor measuring health care quality in a singlelanguage, rather than simply alerting people tomultidimensionality. So the Audit Commis-sion has a real point about the overlap betweenequity and access if we are trying to use the sixdimensions to derive an accounting languagefor health gain. I am not sure that would befeasible. Certainly I do not see it as animmediate priority, but we should be alert tothe dangers of double counting.To date, the main benefit of the six

dimensions seems to have been to expand andclarify people's thinking and to illuminatediscussion about underlying assumptions andvalues - to make practitioners more reflective,in Schon's terms.7 The six dimensions haveprovided a taxonomy (or classification) of thedimensions of quality in the sense thatMintzberg provided one for managementstrategies.8 That is gratifying, but somewhatstatic.

Recognition of multidimensionality is help-ful - along with Donabedian's classification ofstructure, process, and outcome - in findingways of measuring quality and assessing

progress in improving it. Box 6 illustrates whatI had in mind. I am not aware of people yethaving moved far in this direction, though itmay be inherent in the Audit Commission'sapproach. The root idea is that the recognitionof multidimensionality makes it far morepossible to see where any specific criterion fitsinto a comprehensive, rounded view ofquality. It also helps to show what aspects ofperformance are inadequately covered bypresent indicators and suggests where to turnto begin filling the missing part of the jigsaw.If, for example, information about relevance orequity is missing, that immediately suggeststurning for enlightenment to people withsuitable skills rather than to the technicalexpert in the specialty concerned. Thealternative - all too often demonstrated in thehistorical record of NHS quality assuranceinitiatives - is a morass of indicators with littleclarity about their purpose and their relativeimportance. People measure what is ameasureable and collect the results likejackdaws, regardless of value or usefulness.

It is remarkable how extraordinarilycomplicated and confused things rapidlybecame once people start examining thequality of medical care. That is thejustification for trying to maintain someunderlying clarity of concepts, even thoughthe attempt may be laboured and the resultsimperfect.A crucial issue for clinicians and managers

is to recognise that medicine has essential rolesat the level of both the individual and thecommunity. Previously I remarked that anhonest concern about quality, howevergenuine, is not the same as methodicalassessment based on reliable evidence.'

StructureEffectiveness Staffing level and skills

EquipmentAccess to theatres, etc

Acceptability Is setting frightening orreassuring?What provision is there forrelatives (privacy forcounselling, overnightaccommodation)?

Efficiency Avoidance of extravagancein structure, equipment,and staffing

Access

Equity

Relevance Bearing in mind otherneeds, is this service anappropriate use ofresources at the currentactivity and expenditurelevel?

ProcessWorkload (volume ofpatients treated)Compliance with protocols,where relevantData based peer reviewInfection andcomplications ratesIs explanation to relativesrequired and recorded innotes?

Throughput, staffing, etcAdmission and dischargearrangementsHow many patientssuitable for admission haveto be refused because theunit is full?Is there any evidence ofbias in who is admitted orhow they are treated?

OutcomeSurvival rates comparedwith similar units formatched cases

Is there follow up ofpatients and of relatives toobtain their opinions andsuggestions forimprovement?

Costs for comparable cases

What acutally happens topatients refused or delayedadmission because the unitis full?Is there any evidence ofbias in outcomes?

How much difference doesthe unit make to survivaland health status, and forwhom?

Box 6 Assessing quality in an intensive care unit

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Equally, an honest concern for the individualpatient, however genuine, is not enough,under conditions of resource constraint. Eventhe individual clinician needs to be aware ofthe impact on other patients of the ways he or

she uses time and other resources. Equally,public health specialists and general managersneed to recognise that a population is made up

of individuals and that quality of health care

functions at both levels. The six dimensionscan be useful in enhancing this awareness

because they actually bridge this gap (J

Mitchell, personal communication). Although(for the moment) they do not divide up neatly,some (for example, effectiveness andacceptability) have power mainly at the level ofthe individual clinical encounter. Others (forexample, relevance and equity) apply mainlyat the collective level.Another insight that may be helpful - even

though it adds to the complexity - is torecognise the distinction between differentlevels of performance standard. The mainpoint of measuring performance is to findways of improving it. Evidence that it can beimproved may well come from comparisonswith other similar units or with the past recordof one's own unit. Or it may come from a

compelling piece of analysis and a pilotproject. Or, at a higher level of theoreticallyattainable performance, there may be a

definable optimum that represents an absoluteconstraint within the limits of availabletechnology. Thus a hierarchy of performancelevels can be envisaged, with a series of risingsteps between current performance and a

theoretical optimum (box 7). This would helpto indicate where the greatest unexploredpotential for improvement lies and at the same

time focus on what the immediate targetsought to be.

Box 7 Stepped levels ofperformance (applicable withinany dimension of quality, to patient episode, or to healthand health care of community)

Putting the dimensions to use

I have already commented on the danger oftaking the six dimensions too literally -

whatever else they are, they are not the lastword on the definition of quality but more ofa starting position. An even greater danger,however, is to separate them into an abstractbox marked "quality" as distinct from makingthem work for their living in the rough andtumble of NHS clinical and managerial life.There is a similar danger with medical

audit. Audit has suddenly become a

widespread, obligatory activity, into whichsome clinicians put large amounts of time andeffort. All too often that effort is not translated

into action because only the enthusiasts are atthe audit meetings, or because those whoattend do not control all the resources

necessary to introduce change, or because ofsome other reason. Should this continue, theenthusiasts are bound to become discouragedand audit be discredited.These concepts and activities are not ends

in themselves but means to ends. The endmust be as high a quality of health care as can

possibly be achieved within the resources

available. Because this is a complex objectiveinvolving trade offs I would argue that theslightly tortuous thinking about conceptsillustrated by the six dimensions is necessary.

But it is certainly not sufficient. Morefundamentally, it is absolutely essential thateveryone involved has a passionate, sharedcommitment to the pursuit of quality.

If there is a Japanese secret, this is it.Quality is not achieved by inspection at theend of the production line nor can it beimposed from above. It is result of the sharedaspirations and concerted efforts of all thoseinvolved, for whom it is a higher priority thanany personal interest. Thus quality in a servicesuch as health care requires eight orientedactions, as follows.(1) Commitment to excellence for those

reliant on the service - excellence judgedby those who rely on it as well as bytechnical experts.

(2) Translation of good ideas into action,often by small incremental, persistent stepsrather than by large leaps, and alwaystested against external indicators ofperformance (such as, in the commercialsector, market share and consumer

expectations).(3) Emphasis on team rather than individual

performance since service depends on a

combination of skills, not just on one

individual or discipline acting alone.(4) Systematic elimination of waste and of

barriers to, and flaws in, high performance:excellence may be hard to define, butfailures that are remediable can be muchmore easily identified and acted on.

(5) Recognition that every job involvesresponsibility (individual and collective)not only for doing the job well but forcontinually finding ways to do it even

better.(6) Use of concepts (like the six dimensions

and measurements of performance)diagnostically to determine when and forwhom intervention to raise quality isjustified and to assess the impacts of theseinterventions.

(7) Development of action oriented measure-

ment systems (as in box 6) that testprogress and hence support continuingimprovement.

(8) Determination to try to see qualityinitiatives always in the broader context ofquality in the system as a whole. Otherwisethere is a danger that any initiative will beat the expense of an unrecognised loss ofquality elsewhere. As John Ruskin said inanother context, "There is only one way of

* Theoretical optimum, within currenttechnologies

* Known attainable level - that is, achievedsomewhere, under realistic operatingconditions

* Current target level - that is, realisticallyattainable on current plans

* Present performance level - showingvariations

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1 Commitment to quality for those served2 Translation of good ideas into action, usuallyby persistent, small steps and tested againstexternal indicators of performance

3 Emphasis on team performance4 Systematic elimination of waste, flaws inperformance, and barriers to goodperformance

5 Recognition of every staff member's dualresponsibility - that is, to do the job well andto find ways to do it better

6 Diagnostic use of quality concepts (forexample the six dimensions) to determinewhen to intervene to raise quality

7 Continual measurement of progress in orderto support improvement

8 Viewing particular quality initiatives withinthe broader context of quality in the systemas a whole

Box 8 Eight laws of implementing quality

seeing things rightly, and that is seeing thewhole of them."

It seems to me essential that we add to theconceptual understanding of the nature ofquality in health care a determined orientationto action, an addition perhaps, of these eightactions (box 8) to the existing sixdimensions.

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Maxwell R. Quality assessment in health. BMJ 1984;288:1470-2.

Donabedian A. The definition of quality and approaches to itsassessment. Ann Arbor, Michigan: Health AdministrationPress, 1980.

Holy Bible. Corinthians II iii, 6.Godber G. Maurice Bloch Lecture. Glasgow: University ofGlasgow Press, 1976.

Audit Commission. Minding the quality: the AuditCommission's role in promoting quality in the NHS (inpress).

Jarman B. Identification of underprivileged areas. BMJ1983;286: 1705-9.

Schon DA. The reflective practitioner. London; TempleSmith, 1983.

Mintzberg H, Waters JA. Of strategies, deliberate andemergent. Strategic Management J7ournal 1985;6:257-72.

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