Quality in health care is the degree to which services increase the likelihood of desired health outcomes and are consistent with current professional knowledge. In public health, quality applies to populations and systems as well as individual services.

Donabedian's model (structure–process–outcome) is the foundation of quality evaluation.

Structure supports process, and process produces outcomes. Outcome measures are the ultimate test but are influenced by many factors outside a program; process measures are more directly under the program's control. Classify a measure by what it counts: delivery of a service is process; change in health is outcome. For example, vaccination coverage is usually a process measure, while the rate of measles cases is an outcome measure.

Institute of Medicine (now National Academy of Medicine) six aims — care should be: Safe, Timely, Effective, Efficient, Equitable, Patient-centered (memory aid STEEEP). The Agency for Healthcare Research and Quality (AHRQ) uses these domains to organize quality measures.

• Effective: evidence-based services for all who could benefit; avoid underuse and overuse.
• Efficient: avoid waste of equipment, supplies, ideas, and energy.
• Equitable: quality does not vary by personal characteristics such as race, geography, or income.

Accessibility includes availability (services exist), affordability, geographic reach, timeliness, and acceptability (culturally and linguistically appropriate). The nurse's personal convenience is not a factor.

Quality improvement (QI) is a continuous, data-driven effort to improve processes and outcomes. Principles of continuous quality improvement (CQI) and total quality management:

• Focus on systems and processes, not blaming individuals
• Decisions based on data
• Customer (client and community) focus
• Involvement of front-line staff and teamwork
• Continuous, not one-time, improvement
• Leadership commitment

Model for Improvement and PDSA. Three questions: What are we trying to accomplish? How will we know a change is an improvement? What change can we make that will result in improvement? Then test changes in rapid Plan–Do–Study–Act cycles (Deming's earlier version: Plan–Do–Check–Act).

Other QI methods and tools

Patient safety culture and just culture. Encourage reporting of errors and near misses without fear of punishment; examine system flaws first, while still holding individuals accountable for reckless behavior. Blame discourages reporting.

Clinical practice guidelines are systematically developed, evidence-based recommendations that reduce unwarranted variation and support decisions; they do not replace clinical judgment.

Public health performance and accreditation (US)

• 10 Essential Public Health Services (2020 revision, equity at the center): (1) assess and monitor population health; (2) investigate, diagnose, and address health problems and hazards; (3) communicate effectively to inform and educate; (4) strengthen, support, and mobilize communities and partnerships; (5) create, champion, and implement policies, plans, and laws; (6) utilize legal and regulatory actions; (7) assure an effective system that enables equitable access to services and care; (8) build and support a diverse and skilled workforce; (9) improve and innovate through evaluation, research, and continuous quality improvement; (10) build and maintain a strong organizational infrastructure. They are organized around the three core functions: assessment (services 1–2), policy development (services 3–6), and assurance (services 7–10).
• Public Health Accreditation Board (PHAB): voluntary national accreditation for state, local, tribal, and territorial health departments. Standards and Measures Version 2022 has 10 domains aligned with the 10 Essential Public Health Services, and requires a community health assessment, community health improvement plan, strategic plan, performance management system, and QI plan.
• Performance management system: set performance standards, measure performance, report progress, and run QI — a continuous cycle.
• Healthy People 2030 provides national objectives and Leading Health Indicators that health departments use as benchmarks.
• The Joint Commission accredits hospitals and many home health and ambulatory organizations. Since January 1, 2026, hospital and critical access hospital programs use National Performance Goals, which replaced the National Patient Safety Goals for those programs; home care, ambulatory, and other programs still use National Patient Safety Goals. CMS quality reporting and value-based programs also drive measurement.

Evaluation criteria in quality work

• Effectiveness: degree to which objectives or intended health results were achieved.
• Efficiency: results relative to resources (cost per case detected, cost per client served).
• Equity: fair distribution according to need.
• Sustainability: whether gains and programs can continue with local resources and support.
• Donabedian's broader "seven pillars" of quality: efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy, and equity.

Example 1 — A process measure (calculated twice). A health department's clinic served 1,200 infants who reached 24 months this year; 1,020 completed the recommended vaccine series on time.

On-time completion = 1,020 ÷ 1,200 × 100 = 85%. The target is 90%, so a QI project is started.

Example 2 — PDSA cycle for that gap

• Plan: fishbone analysis shows missed reminders and limited evening hours; test text-message reminders in one clinic for 1 month; predict a 3-point rise.
• Do: run the test and record data.
• Study: on-time completion in the test clinic rose from 85% to 89% (an increase of 89 − 85 = 4 percentage points).
• Act: adopt reminders, add a second cycle testing evening hours, and spread to other clinics.

Example 3 — Efficiency (calculated twice). A TB screening program spends $24,000 and identifies 8 cases of active TB.

Cost per case detected = 24,000 ÷ 8 = $3,000. A targeted program in a higher-risk shelter spends $12,000 and finds 6 cases → 12,000 ÷ 6 = $2,000 per case — more efficient.

Example 4 — Classifying measures for a hypertension program

• Structure: number of trained staff and validated blood pressure devices
• Process: percentage of enrolled clients whose blood pressure was measured at every visit using the correct technique
• Outcome: percentage of enrolled clients with controlled blood pressure

• Collect accurate data and document care completely — measures are only as good as the data.
• Participate in QI teams, PDSA cycles, and root cause analyses.
• Report errors and near misses through the organization's system.
• Follow evidence-based guidelines and standing orders.
• Use performance data to advocate for staffing, resources, and equitable services.
• Support accreditation readiness (policies, documentation, workforce development).

• Patient Safety and Quality Improvement Act of 2005: creates Patient Safety Organizations and gives legal privilege and confidentiality protections to patient safety work product reported to them, encouraging voluntary reporting.
• Confidentiality of QI data: use de-identified data where possible; follow HIPAA (QI is a permitted "health care operations" use).
• QI vs. research: routine QI generally does not require IRB review, but projects designed to produce generalizable knowledge for publication may.
• Accountability and transparency: public reporting of performance supports trust; data must not be manipulated to meet targets.
• Equity: stratify measures by race, ethnicity, language, income, and geography to detect disparities.

Case 1 — Medication error in a home visit program. A nurse gives the wrong insulin dose because two look-alike pens are stored together.

Correct action: care for the client first, report the event, and join an RCA that examines storage and labeling systems.

Why: just culture focuses on system causes; reporting enables prevention.

Case 2 — Choosing a measure. A supervisor wants to judge whether a TB program is effective.

Correct action: use an outcome measure such as the cure rate (and relapse rate), not the number of staff or clinic hours (structure). Treatment completion is a useful process measure alongside it.

Why: effectiveness is judged by health results; completion shows the service was delivered.

Case 3 — Improving access. Clients miss prenatal appointments because the clinic closes at 4 p.m. and the bus stops at 5 p.m.

Correct action: map the process, test extended hours with a PDSA cycle, and track first-trimester visit rates.

Why: timely, accessible, client-centered care is a quality aim.

• Calling a count of staff or equipment a process measure — it is structure.
• Calling a rate of services delivered (prenatal visit attendance, vaccination given) an outcome — usually process.
• Confusing effectiveness (achieving results) with efficiency (results relative to cost).
• Treating QI as a one-time audit rather than a continuous cycle.
• Blaming individuals instead of analyzing systems.
• Believing accreditation guarantees good outcomes — it verifies capacity and processes.
• Mixing up RCA (after an event) with FMEA (proactive).
• Mislabeling the PDSA "Study" step as "Do."

• Donabedian: structure (resources) → process (what is done) → outcome (health results).
• IOM six aims: safe, timely, effective, efficient, equitable, patient-centered.
• CQI: data-driven, system-focused, continuous, team-based; PDSA (Plan–Do–Study–Act).
• Tools: fishbone (causes), Pareto (80/20), run/control charts (variation), RCA (after event), FMEA (before event).
• Just culture encourages reporting; focus on systems.
• 10 Essential Public Health Services (2020 revision) organized under assessment, policy development, and assurance, with equity at the center.
• PHAB Version 2022: 10 domains aligned with the Essential Services; voluntary accreditation of health departments.
• Efficiency = results per cost; effectiveness = achievement of objectives; equity = fair distribution by need.