Sheldon T A
University of York.
Qual Health Care. 1994 Jun;3 Suppl(Suppl):41-5. doi: 10.1136/qshc.3.suppl.41.
In summary, though the notion of "quality of care" has become fashionable, most of the focus has been on initiatives such as the patient's charter, waiting times, quality of the physical environment, patient centredness in outcomes measurement, etc. Nevertheless, at the heart of quality must be the effectiveness and cost effectiveness of interventions. Without ensuring that health technologies are effective and are delivered appropriately then many of the other dimensions of quality may simply be window dressing. Substantial variations in the rates of procedures, the way in which similar patients are treated, and the degree to which professionals often ignore the best scientific evidence have all been well documented. The NHS needs methods for ensuring that the effectiveness dimension of quality is brought to the fore and becomes a routine part of quality assessment and activity. Clinical autonomy can no longer be an excuse for inappropriate care. The challenge for the future is twofold: to increase the amount of health technology assessment carried out and to develop methods of ensuring that health care converges with this best practice--that is, the promotion of evidence based practice. By introducing evidence based clinical guidelines and associated utilisation review and persuading purchasers to "purchase protocols" rather than just procedures the effectiveness dimension may become more routine, but it will require a radical rethink of the type of data collected and the way in which the purchaser provider split is managed.
总之，尽管“医疗质量”的概念已变得流行起来，但大部分关注都集中在诸如患者宪章、候诊时间、物理环境质量、结果测量中的以患者为中心等举措上。然而，质量的核心必须是干预措施的有效性和成本效益。如果不能确保卫生技术有效且得到恰当实施，那么质量的许多其他方面可能仅仅是表面文章。手术率、类似患者的治疗方式以及专业人员常常忽视最佳科学证据的程度等方面存在的巨大差异都已有充分记录。英国国家医疗服务体系（NHS）需要一些方法来确保质量的有效性层面得到凸显，并成为质量评估和活动的常规组成部分。临床自主权再也不能成为不恰当医疗的借口。未来的挑战有两个方面：一是增加所开展的卫生技术评估的数量，二是开发方法以确保医疗保健与这种最佳实践接轨——即推广循证实践。通过引入循证临床指南及相关的使用审查，并说服购买方“购买方案”而非仅仅是程序，有效性层面可能会变得更加常规，但这将需要对所收集数据的类型以及购买方与供应商分离的管理方式进行彻底反思。
