So, what's quality?  That's the question just about everyone is asking lately, whether they're calling it outcomes, or evidence-based practice, or best practices.  How do you define it?

Ask your friends and colleagues.  I did.  One nurse told me she thinks quality is whatever anybody says it is, because it is perceived.  Another, an executive employed outside of health care, said, “quality equals expectations over performance.”  One friend said quality care is “timely, sensitive, and responsive.”  Another said quality care is “delivered by a responsible expert.”  My 10-year-old daughter thinks “quality happens when nurses give you good service and helpfulness, and when they make a good impression.”

I think quality care is getting what you need, when you need it. But like so much else in health care, it's not that simple.  If we're honest, we recognize that quality also involves cost, access, standards, and some very tough ethical issues.

Here's an example of how difficult quality can really be.  Just last week, the U.S. Preventive Services Task Force released a 933-page paperback, Guide to Clinical Preventive Services.  The book, based on the most comprehensive evaluation and synthesis of preventive interventions ever, offers a blueprint for preventing premature deaths and  injuries and other types of morbidity.

In one chapter, there is a description of how a regimen of zidovudine (AZT) begun during weeks 14 and 34 of pregnancy and continued through delivery and for six weeks in newborns significantly reduces perinatal HIV infection in babies born to HIV positive mothers.  With the treatment, 8.3 percent of the infants developed HIV; without it, 25.5 percent did.

The quality question I'm wrestling with is this:  If it's true that the early treatment of pregnant women can significantly reduce HIV infection in their newborns, then should we require all pregnant women to be tested for HIV?  After all, we require that children get fully immunized before we let them start public school.  If HIV testing were required of pregnant women, the quality of care for the infant would most likely improve, sometimes virtually eliminating the risk of contracting the disease.  

But, if you look at the situation from the perspective of the pregnant woman, freedom to avoid an HIV test may be considered quality care.  In fact, if a woman were reluctant to get a required HIV test, she might avoid getting any prenatal care, and that could make her more likely to develop other problems with her pregnancy.

If we did decide to mandate testing, should we then decide to mandate treatment?  What if a woman couldn't afford the expensive drugs she'd need?

It doesn't stop when the baby is born.  If an HIV-positive mother breast-feeds her baby, the chances of transmission to the baby increase by an additional 14 percent.  Does quality care mean saying that women with HIV can't breast-feed?  Whose definition of quality care should it be?

In this country, we've been offering HIV testing to pregnant women, but not requiring it. Does that approach constitute quality care?  If you were charged with advocating solely for the newborn-to-be, would you argue that testing the pregnant woman was the highest-quality policy?

If we heard children were dying of polio in this country because they were not immunized, would we feel that our system was providing quality care?  Then why don't we have the same concern when children are born HIV-positive who may have been able to escape the disease, if only their mothers had opted for testing or treatment while pregnant?  Here's one of many reasons the search for quality health care is so complicated.  Polio is a socially and politically neutral disease, so we can ask dispassionate questions in our search for workable, high-quality policies. But that's not true of all diseases, and as we work toward quality, we need to recognize that sometimes factors outside of health care influence our decisions.  But should we let them?

The good news is that we're getting better at asking questions and getting data.  The bad news is that the science of quality is still young.

Barbara Bronson Gray, MN, RN
Editor in Chief