Determinants of Good and Poor Quality as Perceived by US Health Care Managers: A Grounded Taxonomy Based on Evidence From Narratives of Care

Document Type


Publication Date




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.




Emerald Publishing Limited

Publication Information

Journal of Health Organization and Management