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The Six Domains of Health Care Quality — New Considerations

Healthcare organizations have been using a quality improvement framework consisting of six attributes — safe, effective, patient-centered, timely, efficient, and equitable — for decades. But new research has expanded the framework to include elements that address more recent challenges in healthcare and in society.

Why the Six Domains of Health Care Quality emerged

Recommended by the Institute of Medicine (IOM, now the National Academy of Medicine), an American nonprofit, non-governmental organization in 2001, the six domains originated as a response to a book it published in 2000, To Err Is Human. The book brought attention to the high number of patient deaths from medical errors compared to other causes that had fewer fatalities but garnered far more public attention — such as motor vehicle accidents, breast cancer, AIDS, and workplace injuries.

Focusing on individual errors or specific cases to eliminate the causes, the authors reasoned, would not be as effective as adopting a systemic approach. By focusing on the six domains as an operational framework, healthcare organizations would have a higher probability of both reducing errors and improving the overall quality of health care that they provide.

Another benefit of the framework was that it could serve as a communication tool to help patients assess care quality and their satisfaction with the care they received.

What’s missing from the Six Domains?

In 2020, researchers from Ireland, the U.S., and Belgium suggested updates to the Six Domains framework to reflect the evolution of healthcare over the past two decades.

  • They proposed sustainability as an additional domain of quality.
  • They suggested that the domain of safety include accessibility as well as transparency, privacy, and psychological safety as missing from the original model.
  • Their revised model also listed the underlying values of partnerships and coproduction; dignity and respect; kindness and compassion; and holistic well-being that organizations should carry through all their processes.
  • They observed that the domain of equity should include reducing variation in care and attention to the social determinants of health to emphasize that everyone should receive the same level of care no matter who or where they are.

These proposed changes acknowledged that challenges such as climate change, the internet and digital media, COVID-19, the increasing complexity, diversity, and inequities within health care, and other developments have altered how we view and measure quality.

Defining the Six Domains of Health Care Quality

Each of the original six domains of health care quality corresponded to specific components of practice. AHRQ defined each of the domains as follows:

  • Safeavoiding harm to patients from the care that is intended to help them.
  • Effectiveproviding services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
  • Patient-centeredproviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
  • Timelyreducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Efficient avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitableproviding care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

In the years after publishing the framework, AHRQ noted that studies found that healthcare organizations had addressed safety and effectiveness extensively, timeliness and patient-centeredness moderately, and efficiency and equity least. This imbalance led researchers to suggest the additions to the framework mentioned in the previous section.

Determining measures for each of the Six Domains

Categorizing and selecting appropriate measures to improve quality across the six domains helps narrow the scope of processes to those that have the potential to create the greatest improvement. AHRQ recommends using the Donabedian model, named for the physician and researcher who formulated it. Using this model, aspects of quality fall into one of the following three classifications:

  • Structural measures — How well do a healthcare organization’s capacity, systems, and processes support high-quality care? For example, does the organization have adequate facilities, staff, and resources to serve its patient populations?
  • Process measures — How well does a healthcare organization serve patients within generally accepted recommendations and evidence-based guidelines for clinical practice? For example, what percentage of people receive preventative services?
  • Outcome measures — How does a healthcare organization positively or negatively impact the health status of its patient population? For example, what are the rates of satisfactory outcomes, surgical complications, or hospital-acquired infections?

The importance of data collection for measuring health care quality

Without reliable data, measuring quality can be difficult or inaccurate. Establishing a new data collection process might be necessary. But your organization most likely already has a wealth of data for compliance reporting that could also serve for quality improvement. Consider the following data sources:

  • Administrative data includes data gathered from claims, encounters, enrollment, and providers, such as type of service, units of service, diagnosis and procedure codes, locations, and amounts billed and reimbursed. Disadvantages of this type of data can be a lack of clinical details, accuracy, completeness, or timeliness.
  • Patient medical records include documentation of patient histories and care. Disadvantages can be limitations on extracting or aggregating data while adhering to patient privacy protocols or having to convert data from non-digitized formats.
  • Patient surveys include self-reported information from patients about their health care experiences. Disadvantages are the cost of administering surveys and possible inaccuracies based on how survey questions are worded, how the survey is conducted, and the representation and number of respondents.
  • Standardized clinical data includes data reported to governmental compliance entities. A disadvantage could be whether this data includes what your organization seeks to track for quality.

AHRQ also lists patient feedback as a possible data collection source. This type of data comes in the form of comments or testimonials that patients may voluntarily share with a healthcare organization or with third-party information sources. Drawbacks to using this type of data to inform quality measures are possible biases from one-sided perspectives and insufficient sample sizes. AHRQ cautions against using it without also using more robust data sources that can give a more complete picture of your organization.

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Key takeaways from new research

The new research on health care quality measures suggested that a failure to address components missing from the original six domains has led to risk and harm to vulnerable populations — both patients and professionals. Here are key takeaways:

  • Healthcare professionals should focus on health maintenance, preventative care, and the common good more than on managing disease.
  • Quality of care should be measured by how well providers meet the needs of patients and professionals rather than meeting the needs of the healthcare system.
  • Wellness, equity, and health are interrelated, as are personal health and public health.
  • Providers and clinicians should emphasize health care as a service to create positive health outcomes for more people.
  • Healthcare providers should address societal issues such as structural racism and inequalities, including food insecurity, gender inequality, marginalized populations, and violence.
  • Kindness and compassion are not a side issue; rather, they are the “glue of cooperation required for progress to be the most beneficial to the most people.”

Updates from the National Academy of Medicine

In the intervening 20 years since To Err is Human, the IOM (now the National Academy of Medicine),  also updated its own work, publishing additional reports. One such report updated the original six domains by recategorizing equity as a “crosscutting dimension” that affects all domains, along with value. It also suggested care coordination and health systems infrastructure capabilities as new domains.

More recently, it considered the addition of health literacy, language access, and cultural competency as important concepts that have an impact on quality, commissioning a paper from the National Committee for Quality Assurance (NCQA) in 2015 to explore quality measures for these potential domains.

Trends indicate that broader definitions of quality will emerge in response to the continued elusiveness of ensuring quality health care for everyone. While health care has experienced tremendous advancements in the past 20 years, new demands continue to move the goal further out of reach. Quality frameworks will need to continue to evolve to keep up with these societal challenges.


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