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Accred Qual Assur (2004) 9:92–95DOI 10.1007/s00769-003-0677-x

P. P. M. Harteloh

Understanding  the quality conceptin health care

Published online: 30 July 2003© Springer-Verlag 2003

quality assurance to the quality of care.Several attempts to overcome these prob-lems have been made. Some try to reachconsensus on guidelines or rigorous stan-dards for the quality of care, some stress theneed for scientific evidence of the effects of quality assurance; others focus on measure-ments and facts or on the assumptions of quality assurance and its possible applica-tion to health care [8]. Understanding thenature of something abstract like ‘quality’seems to be difficult. Recently, Triadou(2002) even postulated a need to invent apostmodern quality concept which suits thecontemporary nature of medicine [7]. Inthis paper, I will explore the nature of the

quality concept in order to propose a se-mantic rule as a criterion for defining quali-ty in health care. The criterion will be test-ed against the ISO 9000 definition of quali-ty. As an answer to Triadou’s call, I will ap-ply the semantic rule to medicine in orderto explore how the meaning of qualitycould be mediated to medical practice.

 The nature of the quality concept

Quality is an old concept. The current wordfor designating it stems from the Latin word‘quale’ (‘qualitas’), a translation of the Greek 

word ‘poios’ (‘poiotes’). Originally, the wordwas undetermined. It was used both in an in-terrogative sense and as an adverb1.

The Greek philosopher Plato (428–348BC) is the first to give it a definite mean-ing. In Plato’s dialogue ‘Theaetetus’, Socra-tes says:

Maybe you think the word quality isstrange. Maybe you don’t understand thisabstract term. Therefore I will explain it bygiving an example. That which causes per-ception, such as warmth or white, is notwarm or white as such. Something be-comes warm or white. An object does notexist as such, not as a cause of perception,nor as observer. Observer and object meet,

whereby something becomes qualified [9]2

.

Here, Plato clearly introduces the word‘quality’. He coins the term by playing alanguage game: ‘how’ (‘poios’) becomes‘the how’ (‘poiotes’), a slight differencewith long-lasting consequences as we tryto understand the meaning of nouns in or-dinary language. The context of Plato’s re-mark is formed by a discussion on percep-tion. The uniformity and more permanentcharacter of our thoughts, in contrast to thegreat diversity and heterogeneity of ourperception, are the objects of reflection.For example, we speak of ‘a tree’. A tree isthe cause of a many different sensations(colours, smells, forms, etc.) and it changeswith the different seasons (spring, summer,winter, etc.). However, we continue tospeak of the (same) tree and capture itsidentity by using the (same) word. To un-derstand and explain this, Plato postulatesabstract, unchangeable objects of thought,forms or ideas, ‘qualities’, which conceptu-ally determine the properties of objects,persons or events in reality.

It is important to notice that Plato intro-

duces the concept by giving an example.From a linguistic point of view, quality is aprimary concept3.

Knowledge on a primary concept doesnot stem from a formal definition—a pri-mary concept is known without the abilityto define it—but from correct applicationof the concept by examples, e.g. knowl-edge of beauty is acquired by looking atobjects, called beautiful4.

The use of primary concepts dependson the ability of persons to relate the con-cept to situations in which their use is ap-propriate. Its meaning is constructed incommunication. Wittgenstein argues thatthis communication process is guided by

(implicit) rules [13]. A speaker has inten-tions, and by using a concept she causes aneffect within the listener. If the rule fol-lowed by the listener complies with the one

DISCUSSION FORUM

Abstract During the past three decadesthere has been an intense debate on thequality of health care. Errors in medicine,practice variations, competence of physi-cians, scarcity and lack of resources haveall been reasons for discussing the qualityof care. A clear definition of quality shouldexplain the nature of the debate, improveuniformity of speech and facilitate mean-ingful actions such as quality assurance orquality improvement. However, in duecourse many different definitions havebeen proposed and principles of quality as-surance in health care have been frequentlyquestioned, because of their industrial na-ture. It raises questions on our understand-

ing of quality in health care. In this paper,we (i) explore the nature of the qualityconcept, (ii) explain its meaning by Witt-genstein’s theory on rule-following, and(iii) argue for understanding medical careas a reflexive practice, in order to integratethe meaning of quality in medical care.

Introduction

During the past three decades there hasbeen an intense debate on the quality of health care. Errors in medicine, practicevariations, competence of physicians, scar-

city and lack of resources have all been rea-sons for discussing the quality of care [1].A definition of quality should explain thenature of the debate, improve uniformity of speech and facilitate meaningful actionssuch as quality assurance or quality im-provement [2, 3]. However, in due coursemany different definitions have been pro-posed and principles of quality assurance inhealth care have been frequently ques-tioned, because of their industrial nature [4,5, 6, 7]. This hinders the contribution of 

Papers published in this section do not necessarily reflect the opinion of the Editors,the Editorial Board and the Publisher. Apart from exceptional circumstances,they are not submitted to the usual referee procedure and go essentially unaltered.

1 ‘What’ could be a contemporary exampleof such a use: (i) what? (ii) what! (iii)‘what I wish to reflect on ...’2 An older text where we find the wordstems from Demokritos (6th century BC).He speaks of atoms as: ‘the void is filledwith a moving substance, unfinite, undivis-ible and uniform, without quality (apoious)and not sensitive to any influence fromwithout’ [10].

3 A theory on primary concepts also exem-plifies a belief on the relationship betweenlanguage and the world. According toRussell: ‘Since all terms that are defined,are defined by means of other terms, it isclear that human knowledge must alwaysbe content to accept some terms as intelli-gible without definition in order to have astarting point for its definitions’ [11]. Pri-mary concepts are the atomary units of our

conceptual apparatus.4 In the debate on health care, the qualityconcept sometimes still reveals itself asprimary: ‘Quality is an abstract concept,like honour or love. Like them, it is under-stood emotionally and irrationally; likethem it is defined somewhat different byeach individual, although members of agiven culture generally agree on some ba-sic characteristics of a definition; likethem, it becomes incorporated into each in-dividual’s set of personal values’ [12].

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used by the sender of the message, infor-mation is transferred. Both follow semanticrules for interpreting the concept in orderto communicate its content. It is in thissense that concepts have autonomy overspeakers or listeners and are an objectivecarrier of meaning.

A semantic rule is necessarily interpret-ed by persons from a personal point of view. In this sense, quality is in the eye of the beholder. A patient will speak aboutquality in terms of expectations and per-ceptions of medical care, the professionalwill speak of the effect of medical inter-ventions and scientific knowledge of itspossibilities, the manager will speak of thenumber of interventions delivered in rela-tion to the available materials and man-power, health care insurers want value formoney, and the government will judge theperformance of the health care system byits value as compared to other objectives of society (education, work, comfort, safety).The quality concept seems to express a re-lationship between possibilities realised onthe one hand and a normative frame of ref-erence on the other. This seems to be thesemantic rule for interpreting the quality

concept in practice. In health care, ‘possi-bilities realised’ can be ‘care, health, dis-abilities, handicaps, mortality, patient satis-faction, perceptions, or structural proper-ties of health care organisations’. The nor-mative frame of reference consists of norms and values, such as ‘professionalcriteria or standards for practising medi-cine, guidelines, expectations of patients,ideals or desires of society, and culturalvalues’. A well-formed definition of thequality concept has to express a relation-ship (ratio, degree, discrepancy, difference)between these two variables (see Table 1).

Defining quality in health care

Under the increasing influence of industrialideas about quality management in healthcare [1, 7, 14], the ISO (International orga-nization for standardization) standards forservice industry [15] are more and moreconsidered a frame of reference for defin-ing the quality of care. The ISO 9004–2defines quality as: ‘the total composite of properties of an entity needed for fulfil-

ment of explicitly stated or self-evident de-mands’ [15]. The variables of the semanticrule can be recognised. The ‘possibilitiesrealised’ is substituted by ‘properties’ andthe ‘normative frame of reference’ by ‘ex-plicitly stated or self evident demands’. Itseems a correct way to define the qualityconcept. However, the reference to a set of 

properties requires an enumeration of prop-erties of a doctor, nurse, hospital of popu-lation to serve as an object of judging thequality of care. This requires a criterion todistinguish aspects of care related to quali-ty from those that are not. Otherwise weare confronted with a potential infiniteenumeration. As in fact a definition has toprovide this criterion, the approach seemsto be circular. It asks for an enumeration,but does not provide a criterion for thisenumeration.

In the ISO 9000:2000 the definition of quality is revised. Quality is defined as a‘degree to which a set of inherent charac-teristics fulfils requirements’ [16]. By re-

ferring to a set of inherent characteristicson the one hand and requirements on theother, this definition seems to meet the se-mantic rule, expressed by the quality con-cept. It suits the intuition on the nature of the quality concept. In the current attemptsto translate the ISO 9000 to health care, itcould be used with a slight addition, alongthe lines of Donabedian’s analysis of quali-ty in health care (the object of attention),e.g. ‘Quality is the degree to which a set of inherent characteristics of the structure,process or outcome of health care organi-sations fulfils the requirements of profes-sionals, patients and society’ [17]. In thisway, it complies with standards of speech

on quality in service industry and healthcare. However, difficulties remain, in spec-ifying the inherent characteristics of medi-cal care and stating the requirements of health care. In fact, the abstract nature of the quality concept requires a continuousattempt to substitute the variables of the se-mantic rule by the actors (doctors, nurses,carers, etc.) or organisations (hospitals,nursing homes, etc.) involved. Therefore,defining the quality of care has to be an in-tegral part of practising medicine.

 The qualities of medical care

For understanding the quality of care, thenature of the quality concept has to betranslated to practising medicine. For this,the semantic rule can be used. Applicationof the semantic rule changes our views onpractising medicine. According to the tra-

ditional models, medical interventions startwith observing symptoms presented by pa-tients. The observations lead to a diagno-sis, a description informing us about a stateof reality. The diagnosis points out the wayto a therapy, the medical intervention assuch, e.g. care, surgery, medication or pal-liation. Observing the effect of a medicalintervention on individual patients (followup) makes this process a cycle. The cycleis repeated until professional insights meetthe needs or expectations of patients [18].

This (rational) structure of modernmedicine makes it a technical act with theintention to control and to change reality,e.g. the health status of persons. It presup-

poses a theory on the aim and function of medical care, necessary for evaluation of medical interventions, and a sense of pur-pose, guiding medical professionals inpractising medicine. This is where themedical care and quality managementmeet. Models for managing quality pre-scribe evaluation and (rational) control astools for quality assurance and improve-ment. These models are often framed interms of cycles. The Deming cycle—a se-quence of plan, do, check, act—seems tobe the paradigm for quality models (ISO9000:2000, EFQM, etc.). The semanticrule is at its heart. A normative frame of reference (a plan) is related to possibilities

realised (check ) by actions (do) on the onehand and an evaluation ((re)act ) at the oth-er hand. In this, the structure of quality as-surance reflects the structure of the medi-cal practice (Fig. 1). Applying the princi-ples of quality assurance, adds a new levelto practising medicine, both in a formal(from single to double loop learning, etc.)and in a social way (from individual prac-tice to peer review, quality systems, etc.)[19]. The quality of medical care is nowchanging. A set of medical actions is relat-

Table 1 The nature of the quality concept

Primary conceptAbstractAssociated with subjects using itAssociated with (aspects of) the object

of attentionContext dependentDegree of perfection/gradation of the goodA semantic rule

Fig. 1 The structure of medical practice

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ed to a plan as its normative frame of refer-ence and an evaluation of its possibilitiesrealised.

A semantic rule is not only translatingthe quality concept to practising medicine,but translating norm and values into factsas well. For example, what once was anorm, e.g. caesarean section rates below10%, becomes a fact in due course, elicit-ing new norms, e.g. caesarean section ratesbelow 5%, when the rule is reapplied in thenext review cycle, until values such as eq-uity, safety, effectiveness, etc. (Table 2) arerealised. Values and facts change as thesubstitution of the variables in the semantic

rule changes. This reflexive process leadsus from the aims of medicine, traditionallyframed in terms of (releasing) patient wel-fare (wellbeing and doing no harm), patientautonomy and social justice [20], to itsoriginal intention, charitas (Table 2). Relat-ing facts to values is a function of the se-mantic rule. A possibility is realising itself in a particular time and place. By integrat-ing quality management principles in thestructure of medical interventions this factis related to norms and values. In this way,

quality management principles mediate asense of purpose by applying a semanticrule to medical practice. A conscious appli-cation of the semantic rule provides medi-cal acts with a meaning.

Conclusions

Starting point for understanding the mean-ing of quality in health care is understand-ing the conceptual properties of the qualityconcept. By nature, ‘quality’ is a primaryconcept. Its meaning lies in its use and is

exemplified by examples (e.g. definitions).This use is guided by (semantic) rules. Ex-ploration of such a rule is an important ele-ment of fundamental research on the quali-ty of care. A semantic rule for interpretingthe quality concept defines it as a ratio of possibilities realised on the one hand and anormative frame of reference on the other.It can be used for (i) defining quality inhealth care; (ii) understanding the princi-ples of quality management, and (iii) turn-ing medicine into a reflexive medical prac-

tice by relating facts to values. Followingthe rule is a way to mediate a sense of pur-pose to medical practice.

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Table 2 Norms and values in medicine and quality assurance

Aims of quality assurance Values of quality assurance Contemporary values Primary valuein health care in health care of medicine of medicineFacts-values Secondary qualities Primary qualities

(i) Reduce the use of inappropriate surgery, (i) Equity Patient welfare: Charitashospital admissions and diagnostic tests wellbeing, doing no harm

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(v) Adopt simplified formularies and streamline (v) Timelinesspharmaceutical use

(vi) Increase the frequency with which patients (vi) Efficiencyparticipate actively In decision making aboutmedical interventions

(vii) Decrease uninformative waiting of all types (vii) Access

(viii) Reduce inventory levels

(ix) Record only useful information only once(x) Reduce the total supply of high-technologymedical and surgical care and consolidatehigh-technology services into regionaland community-wide centres

(xi) reduce the racial gap in health statusbeginning with infant mortalityand low birth weight

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P. P. M. Harteloh (✉)Department of Health Policyand Management,Erasmus MC/ Erasmus University,P.O. Box 1738, 3000 DR Rotterdam,The Netherlandse-mail: harteloh@bmg.eur.nlTel.: +31-10-408 8541

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