People constantly look for quality products and services, particularly healthcare organizations. Higher healthcare quality results in satisfaction for the patients, employees, and suppliers. If the quality of healthcare services improves, costs decrease, productivity increases, and better service would be available for patients, which enhance organizational performance, resulting in long-term working relationships for both employees and suppliers. Specifically, Leebov and colleagues (2003) argue that quality in healthcare means “doing the right things right and making continuous improvements, obtaining the best possible clinical outcome, satisfying all customers, retaining talented staff and maintaining sound financial performance” [1]. In many countries, health stakeholders proposed different dimensions of quality to design conceptual frameworks and provide a system in assessing health services performances such as individual ability of practitioners, work teams and health services mechanisms, strategies or intervention [2]. In this paper, we provide a brief overview of the evolution of the concept of quality improvement. Specifically, we define quality improvement as it exists today in healthcare organizations, provide an overview of quality improvement frameworks over the years, and finally, get to the examination of the proposal by AsIQuAS on its latest quality-improvement conceptual framework.

This study, therefore, aims to provide a framework for healthcare service quality by exploring the perspectives of various previous studies. Analyzing the narrative, theoretical and conceptual works from past academic and grey literature was fundamental to developing this paper. Preliminary research was undertaken to investigate the evolution of the conceptual frameworks of quality in healthcare and the different health system efforts to implement them. Additional works were hand-searched and selected, focusing on relevant literature, critical policy and organizational documents.

Concept of quality improvement in healthcare

In the healthcare industry, Batalden and Davidoff [3] have defined quality improvement as a mixture of efforts by everyone involved, from clinicians to patients and systems of care to improve clinician knowledge and skills and enhance patient health. Quality improvement attempts to provide cost-effective, efficient, better quality healthcare for patients while improving processes within the healthcare industry. It is definable as a systematic continuous approach that aims to solve problems in healthcare, improve service provision and provide better outcomes for patients [4].

Development of quality improvement frameworks in healthcare

In several countries, healthcare organizations identified strategies for raising awareness of quality care. Further understanding the evolution of the conceptual frameworks requires identifying different health system efforts to provide the critical elements demanded and identifying indicators to measure various aspects of healthcare systems’ quality. Different conceptual frameworks for health system performance assessment have been proposed at an international and national level [5]. We explored and selected the contribution of some associations in the continuous strategic planning process.

WHO four key elements: One of the first attempts to define quality in healthcare was made by the World Health Organization (WHO) in 1983. WHO, instead of providing a descriptive definition of healthcare quality, decided to specify the following four “dimensions” (or “key elements”) of quality in health services: professional competence of healthcare workers; acceptable use of the resources; risk management and patient satisfaction [6].

IOM Six quality dimensions: Years later, in 1991, the Institute of Medicine (IOM) identified patient-centeredness as crucial to quality health care. The IOM proposed a framework that endorsed six key patient-centeredness dimensions to achieve significant gains in the quality of care provided and meet better patient needs and clinicians’ satisfaction [7].

The Canadian Health Indicators Framework (CHIF): In June 2000, WHO conducted a comparison between 191 countries? The WHO based the study on their ability to achieve three goals: improving health, increasing responsiveness to meet the demands of the population, and ensuring that financial burdens were distributed equally. From this analysis, Canada ranks 30th in terms of overall health system performance. To improve its condition, Canada took a broad health performance approach to quantify health and healthcare progress investing in measuring and reporting on the performance of its health system. That has entailed developing and using a multi-dimensional ‘health indicators framework’. The Canadian Health Indicators Framework (CHIF) is divided into four primary levels: health status; non-medical determinants of health; health system performance; and community and health system characteristics. Every level includes different fields or dimensions. It provides data and information used to accelerate improvements in the healthcare system. Every dimension describes and assesses quality relative to users’ needs. We can find the following four dimensions regarding the first level: health conditions, human functions, well-being and deaths. Within the “non-medical determinants of health” level, the dimensions, also four, are health behaviors, living and working conditions, personal resources, and environmental factors. At the healthcare performance level, the six dimensions that we find are acceptability, accessibility, appropriateness, competence, continuity, effectiveness, efficiency, and safety. Finally, the last level comprises three dimensions: community, health system and resources [8].

The OECD Conceptual Framework: Following in the footsteps of the organizations mentioned above, the Organization for Economic Cooperation and Development (OECD) identified priority areas for quality improvement, and directly under his management, the ‘Health Care Quality Indicators’ (HCQI) Project [9]. Was initiated to develop and report common indicators for international comparisons of health care quality. This project represented a new milestone of long-standing international cooperation among countries committed to building a joint base for performance measurement; it was built on the standard dimensions of performance incorporated into a model that borrows heavily from the IOM healthcare quality indicator framework, and it also relies on a modification of the Canadian Health Indicator Framework. The HCQI framework has four interconnected tiers, which represent: health, non-healthcare determinants of health; health care system performance; health system design and context. Effectiveness, safety, timeliness and patient-centeredness are the core quality dimensions. These dimensions are, in essence, those core attributes of healthcare that increase the likelihood of desired outcomes. The proposed HCQI framework highlights two crucial points. Firstly, it allows for the reality that although high-quality health care should produce desired health outcomes and responsiveness to consumers, such outcomes will deviate between and across individuals, societies, and health care systems because of varying preferences, structures, and obligations. It improves coherence and balance and represents an innovative contribution [10].

The Proposal from Asiquas

As observed, many countries and organizations have used the different dimensions of quality to structure conceptual frameworks used to build health services’ performance evaluation tools. AsIQuAS which stands for “Associazione Italiana per la Qualità della Assistenza Sanitaria e Sociale”, is an association that analyzes, develops and proposes scientific activities about the quality of health and social care to design, plan, assess and improve health services in continuity with the activities of SIQuAS-VRQ (Società Italiana per la Qualità nell’Assistenza Sanitaria-VRQ 1984/1999) and SIQuAS (Società Italiana per la Qualità nell’Assistenza Sanitaria 1999/2016. AsIQuAS for developing its framework [annexes n.1] on healthcare quality identifies five macro-categories. First of all, the association for developing its framework on health quality identifies five macro-categories. It then integrates these macro-categories with 14 performance dimensions that include all the performance dimensions proposed by the associations we dealt with previously (WHO, IOM and OECD), and which represent a continuation of the work carried out by SIQuAS in January 2014, where, through the drafting of the document “Carta di Portonovo”, which listed the twelve performance dimensions for improving the quality of health care. The five Macro-categories identified are Values; Actors-centered; Professional quality; Managerial quality and integration, and Continuity of Healthcare. These categories include the fourteen dimensions previously mentioned: accessibility and timeliness; patient acceptability, patient-centeredness and patient empowerment; adequateness of human, structural and technological resources; clinical appropriateness; organizational appropriateness and transparency; professional and cultural competence; effectiveness; efficiency; equity; integration and continuity of care; safety; healthcare workers well-being; patient satisfaction and humanization of assistance. The conceptual framework combines the macro-categories and the fourteen dimensions and subsequently provides definitions for each mentioned dimension.

Value

• Equity: Health assistance does not change concerning the gender, race, ethnicity, geographical location or socio-economic status of the users/patients.
• Humanization of assistance: It is essential to make the areas of assistance, the diagnostic and therapeutic pathways patient-oriented as much as possible, considering his/her physical, social and psychological aspects.

Actors-centred

• Workers’ satisfaction and well-being: Cultural elements, organizational processes and practices vivify a dynamic atmosphere and coexistence in a work context, promoting, maintaining and improving the quality of life and the level of physical, psychological and social well-being of the healthcare working force.
• Patients’ satisfaction: It compares the expectations with which the user prepares to receive the type of service requested and the perceived performance.
• Patients’ acceptability, centrality and empowerment: Providing healthcare services that are respectful and sensitive to individual patients’ preferences, needs and values. It must guide all clinical decisions.

Professional Quality

• Effectiveness: Level of achievement of the health goals defined based on the individual’s health needs (or community) and prosecuted based on the scientific evidence available.
• Clinical appropriateness: It is the correct use of an effective health intervention on the clinical conditions of patients who can benefit from it. It is based on evidence, clinical experience and good practices.
• Professional and cultural competence: It is the proven ability to use personal, social and methodological knowledge and expertise in working or study environments and professional and personal development.
• Safety: It is the ability to ensure the design and implementation of operating systems and processes to minimize the error probability, the potential risks and consequent possible patient harms. It is carried out by identifying, analyzing, and managing risks and possible patient accidents.

Managerial quality

• Efficiency: It is the ability to manage healthcare organizations, optimize resources and reduce/eliminate waste of equipment, supplies, ideas and energies.
• Organizational appropriateness and transparency: Organizational appropriateness relates to providing a service in an adequate and congruent organizational context, considering the clinical complexity of the patient and the type of intervention/assistance to be provided. Organizational transparency is the easiness for users/stakeholders to find, acquire and understand the information required to receive and assess the quality of the service of interest. 
• Accessibility and Timeliness: Accessibility refers to providing healthcare services through operating settings that are easy to reach geographically, with appropriate skills and resources to health needs. Meanwhile, timeliness is the ability of the system to assist promptly with due regard for the expressed and recognized needs.
• Appropriateness of human, structural and technological resources: It is the correspondence and the qualitative/quantitative updating of human, structural and technological resources in compliance with the patients’ actual needs, the national or regional legislation and the validated technological innovations.

Integration and continuity of care

It refers to the provision of health assistance through the implementation of coordination and continuity of care and the interconnection of assistance and services according to people’s health needs and preferences within and between different institutions involved in the patients’ care [11].

Quality is difficult to define because of its subjective nature and intangible characteristics. Healthcare service quality is even more challenging to define and measure than other sectors. Distinct healthcare industry characteristics such as intangibility, heterogeneity, and simultaneity make defining and measuring quality difficult. The complex nature of healthcare practices, many participants with different interests in healthcare delivery and ethical considerations add to the difficulty. Although there are no uniform dimensions and indicators, all these frameworks have a common starting point – the conceptualization of the health system, defined more broadly or narrowly. The proposal from AsIQuAS is one of the most complete. It represents an additional reflection tool to identify the most critical quality dimensions. The conceptual framework provided by AsIQuAS could represent a milestone to define, at a later time, an innovative and complete monitoring system to measure the different dimensions of the quality.

Annexes N.1

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6. H.O (Working Group on the Principles of Quality Assurance; World Health Organization. Regional Office for Europe). The Principles of quality assurance: report on a WHO meeting, Barcelona, 17-19 May 1983.
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10. Carinci F, Van Gool K, Mainz J, Veillard J, Pichora EC, Januel JM, Arispe I, Kim SM, Klazinga NS, et.al. OECD Health Care Quality Indicators Expert Group. Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. Int J Qual Health Care. 2015; 27:137-146.
11. Di Stanislao F. “La Qualità nell’assistenza sanitaria e Sociosanitaria”. Città di Castello-PG.COM. 2021.