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The scientific literature evidences that the quality of care must be improved. However, little research has focused on investigating how health care managers – who are responsible for the implementation of quality interventions – define good and poor quality. The purpose of this paper is to develop an empirically informed taxonomy of quality care as perceived by US managers – named the Integrative Quality Care Assessment Tool (INQUAT) – that is grounded in Donabedian’s structure, process and outcome model.

A revised version of the critical incident technique was used to collect 135 written narratives of good and poor quality care from 74 health care managers in the USA. The episodes were thematically analyzed.

In total, 804 units were coded under the 135 written narratives of care. They were grouped under structure (9 percent, n=69), including organizational, staff and facility resources; process (52 percent, n=419), entailing communication, professional diligence, timeliness, errors, and continuity of care; outcomes (32 percent, n=257), embedding process- and short-term outcomes; and context (7 percent, n=59), involving clinical and patient factors. Process-related categories tended to be described in relation to good quality (65 percent), while structure-related categories tended to be associated with poor quality (67 percent). Furthermore, the data suggested that managers did not consider their actions as important factors influencing quality, but rather tended to attribute the responsibility for quality care to front-line practitioners.

The INQUAT provides a theoretically grounded, evidence-based framework to guide health care managers in the assessment of all the components involved with the quality of care within their institutions.

Identifying the factors that contribute or hinder the provision of good quality care within healthcare institutions, from the managers’ perspective, is important for the success of quality improvement initiatives. The purpose of this paper is to test the Integrative Quality Care Assessment Tool (INQUAT) that was previously developed with a sample of healthcare managers in the USA.

Written narratives of 69 good and poor quality care episodes were collected from 37 managers in Italy. A quantitative content analysis was conducted using the INQUAT coding scheme, to compare the results of the US-based study to the new Italian sample.

The core frame of the INQUAT was replicated and the meta-categories showed similar distributions compared to the US data. Structure (i.e. organizational, staff and facility resources) covered 8 percent of all the coded units related to quality aspects; context (i.e. clinical factors and patient factors) 10 percent; process (i.e. communication, professional diligence, timeliness, errors and continuity of care) 49 percent; and outcome (i.e. process- and short-term outcomes) 32 percent. However, compared to the US results, Italian managers attributed more importance to different categories’ subcomponents, possibly due to the specificity of each sample. For example, professional diligence, errors and continuity of care acquired more weight, to the detriment of communication. Furthermore, the data showed that process subcomponents were associated to perceived quality more than outcomes.

The major limitation of this investigation was the small sample size. Further studies are needed to test the reliability and validity of the INQUAT.

The INQUAT is proposed as a tool to systematically conduct in depth analyses of successful and unsuccessful healthcare events, allowing to better understand the factors that contribute to good quality and to identify specific areas that may need to be targeted in quality improvement initiatives.