Muir Gray: Setting standards for systems of care

Muir GrayRead the rest of this series of blogs about designing and planning population based systems of care here.

Step 5: Setting standards

Having formulated objectives and chosen criteria to measure those objectives, the next stage in the development of a system is to set standards. (Standards can be set for process criteria even in the absence of outcomes.)

Donabedian, in many ways the founder of the healthcare quality movement, said in a lecture that “the quality of a health service is the degree to which it conforms to pre-set standards of goodness.”

When setting standards, it is important to be aware that standards are subjective, and different perspectives exist. A manager may think a service is of good quality, but patients and carers may regard its quality as poor, or vice versa. Many people rate their experience with alternative or complementary medicine as high in quality, whereas many clinicians would regard the service provided as low in value.

It is often useful to set more than one level of standard. In a book popular in the 1990s entitled In Search of Excellence people were exhorted to be excellent. However, exhortations to excellence can be de-motivating to people working in difficult circumstances aware that excellence is the result not only of hard work, but often of the chance coalition of skilful individuals working in a propitious environment. For this reason, it is advisable to set three levels of standard:

  • a minimal acceptable standard, below which no programme of care should fall;
  • an excellent standard, which is reached by the best; and
  • an achievable standard, for example the cut off point between the top quartile and the rest setting standards.

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.