Where are the patients in the quality of health care?

While the achievements of the Organisation for Economic CoOperation and Development (OECD) Health Care Quality Indicators (HCQI) Project [1] are laudable and enable international comparisons of health care systems in terms of a particular type of quality, it is important to remember that quality is not value neutral. As Donabedian pointed out, 1981, explicit measures of quality carry with them the values of those who have defined the measures, and such measures are amenable to being used as instruments of control [2]. Who defines quality and who measures it are pivotal questions for those who engage in its pursuit. However, it would seem there is little consensus about the meaning or measurement of quality from the stakeholders involved in health. Of greater concern is that, despite the apparent plethora of attempts to gauge patient satisfaction with their health care experiences, there is a worrying downgrading of patients' perspective views of what they feel comprises quality health care. In most instances quality health care is assumed to occur with quality medical care [3, 4], including in Donabedian's seminal Structure/Process/Outcomes model [5], yet even physicians have a difficult time agreeing on the nature of quality [3]. In general, to the physician, quality health care leads to 'cure' [5], measured, somewhat naturally, by patient health outcomes. Many of the available indicators used in the OECD HCQI Project can be classified as patient health outcomes. It is not only physicians who judge quality by patient health outcomes. To the nurse quality health care is the process that enables recovery [6]. Thus for nurses the process of health care is the site of quality, yet this is largely assessed by patient health outcomes. Process—what is done—can be more sensitive than out-comes—what happens [7 – 9], yet patient health outcomes are so intrinsically appealing as measures of quality that often, even when purporting to assess process, outcomes are used as indicators [7, 8]. Furthermore, whether indicators of outcomes or process are used, it is easier to use firm, quanti-fiable indicators that adds another problem if the nature of quality is not such that it can be easily quantified. The very nature of a project such as the HCQI Project means that, in order to achieve international viability, the indicators used must be of a concrete nature, whether these be indicators of outcomes or indicators of process. From the above discussion of the centrality of patient health …