When we talk about quality, what exactly do we mean?

It’s a health care buzzword for sure, but when we talk about quality, what do we mean? We can compare the quality of similar things and focus on its absence, but otherwise, putting the idea into words becomes complicated. Context is important. And so is perspective: One’s position within the health care system influences how he defines quality to a larger degree than it does at a restaurant, or in a museum.

To a patient in pain, quality could be found in attentive staff, response to complaints, or a comfortable bed. To an administrator, it might represent compliance with processes and achieving goal metrics. To a provider, it may mean implementation of best practices or capacity for critical thinking.

In operational terms, good decisions are at least where quality begins. Other focuses are important, but they’re different than quality. Our system’s tendency towards survey results (as proxy for quality) feels similar in concept to the treatment of symptoms rather than their cause: their correlation to strong processes might be good, but they’re only tangential if we don’t understand clearly what they result from.

This definition assumes that each decision has an objectively correct, or at least best, answer. Because we enjoy rich and growing bodies of evidence, good quality should be at least proximate to the idea that evaluation and treatment decisions are in line with best care standards. But quality, unless we are no more than specialized technicians, is beyond implementation of guidelines. We sometimes base decisions on incomplete information: we have gut feelings, and those come from experience. Bright, dedicated providers can use those intangibles to great effect, but others can use them to real detriment, and we can’t discern that difference well.

Over time and through many cases, the patients of providers making better rates of best decisions will have better outcomes. These decisions are complex, and their results are not direct or simple to analyze, so we default towards outcomes. But with enough data points, good providers will, by definition, achieve better results than average or worse providers, and the mechanism for that is a better rate of right decisions.

It’s difficult to avoid being results-oriented in health care because each patient presents a single opportunity to get things right. This is different than the stock market, for example, where an investment strategy could bring great results over a decade but lose to the market during a single month or year. It feels wrong to discuss life-and-death decisions as losing to variance, but it happens. Sometimes in visible fashion; for example, an unavoidable surgical complication — but also incrementally in routine decision making, adding to infection risk with a catheter that wasn’t needed. The latter represents an opportunity for quality to produce results just as much as the former.

Different measures become conflated with quality. They aren’t meaningless, but relative to the importance of strong decision making, they’re small — things like hospital food and appearance. Comforts are nice, but our focus on them comes at a cost of attention on something more important. We emphasize these things because they’re easy to change and put into worksheets. And now, some do affect reimbursement. Of course, there are exceptions. When an outcome is foregone, warm blankets and compassionate ears may become highly representative of quality.

Policymakers discuss quality within this paradigm of cost and access. The supposition is that quality improvements come at the cost of access or necessitate greater spending. But maybe high-quality care is the answer to the problems of limited access and unsustainable cost.

Holding providers accountable to deliver quality care was once a provision of the Affordable Care Act, but not one that made it to law. The goal then was to reduce spending on low-value care, but unfortunately, there are vocal groups which benefit from the current lack of oversight.

Defining quality in this way, low-value care takes a different meaning as well. For every illness episode, optimal management has a certain cost, and whatever we spend beyond that is waste. And if we fail in diagnosis, the outcome could be incalculably worse than spending too much. Accepting that best decisions are the fundamental basis of quality necessitates ownership of a large burden of low-value, low-quality care, and that will meet resistance.

If right decision making could be enforced without enormous administrative oversight, it might become a real answer to the problem of cost, and therefore of access. Better accuracy of decision making means less waste, which means reduction of cost, which allows greater access for those limited by finance. We can make it cheaper by making it better, or we can make it cheaper by taking it away from some, and that choice should be simple.

The important questions are whether it’s reasonable to analyze quality at the decision level and whether that’s necessary. We are in short supply of people who can understand the gestalt of these complex decisions as it is, and as much as quality measurement needs data analysis, its facilitation is more fundamental.

Strong organizational cultures that attract people who are dedicated to doing good work for patients are the common thread of our successful health systems. We don’t need to scrutinize every decision to understand that, and having data to show that our best systems are full of providers who make fewer wrong decisions than their peers would not help us to emulate their successes. Paradoxically, understanding and reporting quality may be more complicated than actually generating it. While it’s important to understand the mechanism which leads to quality at its most basic level, the better focus is on understanding how to incentivize that behavior.