Brook R H, McGlynn E A, Shekelle P G
RAND, Health Program, Santa Monica, CA 90407-2138, USA.
Int J Qual Health Care. 2000 Aug;12(4):281-95. doi: 10.1093/intqhc/12.4.281.
The modern quality field in medicine is about one-third of a century old. The purpose of this paper is to summarize what we know about quality of care and indicate what we can do to improve quality of care in the next century. We assert that quality can be measured, that quality of care varies enormously, that improving quality of care is difficult, that financial incentives directed at the health system level have little effect on quality, and that we lack a publicly available tool kit to assess quality. To improve quality of care we will need adequate data and that will require patients to provide information about what happened to them and to allow people to abstract their medical records. It also will require that physicians provide patient information when asked. We also need a strategy to measure quality and then report the results and we need to place in the public domain tool kits that can be used by physicians, administrators, and patient groups to assess and improve quality. Each country should have a national quality report, based on standardized comprehensive and scientifically valid measures, which describes the country's progress in improving quality of care. We can act now. For the 70-100 procedures that dominate what physicians do, we should have a computer-based, prospective system to ensure that physicians ask patients the questions required to decide whether to do the procedure. The patient should verify the responses. Answers from patients should be combined with test results and other information obtained from the patient's physician to produce an assessment of the procedure's appropriateness and necessity. Advanced tools to assess quality, based on data from the patient and medical records, are also currently being developed. These tools could be used to comprehensively assess the quality of primary care across multiple conditions at the country, regional, and medical group level.
现代医学质量领域大约有三十多年的历史了。本文的目的是总结我们对医疗质量的了解，并指出在下个世纪我们可以采取哪些措施来提高医疗质量。我们断言，质量是可以衡量的，医疗质量差异巨大，提高医疗质量很困难，针对卫生系统层面的经济激励措施对质量影响甚微，而且我们缺乏一个可供公众使用的质量评估工具包。为了提高医疗质量，我们需要足够的数据，这就要求患者提供有关自身情况的信息，并允许他人提取其病历。这还要求医生在被询问时提供患者信息。我们还需要一种衡量质量并报告结果的策略，并且需要将可供医生、管理人员和患者群体用于评估和提高质量的工具包公开。每个国家都应该有一份基于标准化、全面且科学有效的衡量标准的国家质量报告，该报告描述该国在提高医疗质量方面的进展。我们现在就可以行动起来。对于医生所进行的占主导地位的70 - 100种诊疗程序，我们应该建立一个基于计算机的前瞻性系统，以确保医生询问患者决定是否进行该诊疗程序所需的问题。患者应核实这些回答。患者的回答应与检查结果以及从患者医生处获得的其他信息相结合，以对该诊疗程序的适当性和必要性进行评估。目前也正在开发基于患者数据和病历的先进质量评估工具。这些工具可用于在国家、地区和医疗集团层面全面评估多种病症下的初级医疗质量。
