COMMENTARY Quality of Care ■ KENNETH V. ISERSON, MD, MBA, FAAEM, FACEP “Q uality of care,” due to both its nebulous nature and its vital importance, has always been a much-discussed issue in medical ethics. For example, the Codes of Hammurabi, the Hippocratic writings, and other early med- ical treatises discuss quality of care. Today, the changing goals and priorities within health- care systems and the ongoing attempts to restructure local, state, and national health treatment delivery systems have increased the importance of defining the term “quality.” Healthcare professionals commonly face conflicts between what they see as their obligations to their patients and the legal-economic constraints imposed upon them by legislators and healthcare administrators. Yet with increas- ing pressure for greater cost-containment, and with the advent of alternative healthcare delivery systems, it has become more difficult for healthcare professionals always to act in the best interests of their patients. “Quality” refers to the essential character or nature of medical care. It is an elusive concept. The definition, in part, relies upon the perspective of those applying the term— healthcare providers, patients, or those who regulate the profession: Ⅲ Medical professionals often view quality of care as encompassing the best method of practicing medicine. However, they use their own “process standards,” sometimes called clinical protocols, as their true yard- stick. Ⅲ Patients view quality medical care as including appro- priate, rapid, and caring treatment—at a low cost. Ⅲ Regulators increasingly see quality care as the deliv- ery of measurably improved outcomes using limited resources. Each of these perspectives has some validity. Ken Iserson is a professor of emergency medicine and director of the Arizona Bioethics Program at the University of Arizona in Tucson, as well as the author of several books and a member of the JUCM Advisory Board. He is a frequent contributor to JUCM. 28 JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | M a y 2 0 0 7 Urgent Care Medicine and Quality of Care The medical practitioner’s goal has always been to benefit the patient whenever possible. Echoing comments from physicians throughout the ages, the American Medical As- sociation defines quality of care as “the degree to which care services influence the probability of optimal patient out- comes.” 1 Many other physician organizations use the term “quality” without defining it—assuming, incorrectly, that there is a commonly understood meaning. “A breakdown in any part of the team can adversely affect the quality of care delivery.” Patients expect quality care from their healthcare providers; providers expect this from themselves. Yet, in our beeping, buzzing, and flashing medical environment, the goal of providing quality care can be lost as the urgent care medical practitioner is inundated with brief visits from new patients with serious and not-so-serious problems, contin- ually short on time and personnel, necessarily focused on a single patient complaint, and harried by constantly chang- ing administrative constraints. Since urgent care medicine relies on teams of individuals working together to achieve optimal patient care, a break- down in any part of the team can adversely affect the qual- ity of care delivered. In arranging their schedules, for instance, urgent care providers frequently make difficult decisions affecting their quality of life and patient care: working multiple sequential shifts (perhaps due to staffing problems) and the resulting lack of sleep, for instance, may result in differing practices and abilities at different spots in the schedule. Quality may also suffer due to distress after conflict- laden interactions with other healthcare practitioners (re- w w w. j u c m . c o m