Quality in Health Service Organisations

1. Quality in Health Service Organisations

2. Introduction • Over the past decade, healthcare has advanced enormously - both in terms of improved technology and clinical methodology.

3. Life expectancy has risen • Expectations have risen • Costs have risen • Quality risen? • Safety risen ?

4. Questions remain open to debate • What is quality health care? • What constitutes quality health care? • How can quality be measured? • How can quality of care be improved? • What is the cost of quality care?

5. Systems Theory • Within an organisational context, systems theory provides a framework for analyzing systems (and subsystems) • enables organisations to re-design systems where necessary to improve processes and outcomes

6. endeavours to find a unified perspective of all components of an organisation, • enabling an organisation-wide approach to transformation • Examines the interrelatedness of its subsystems and feedback from internal and external customers.

7. Systems theory has also provided the foundation for constructs such as ‘systems thinking’ to emerge in the management literature. • ‘Systems thinking’ is the belief that systems can only be understood once all component parts (ie subsystems) are understood within the context of their interrelationships

8. changes to any part of a system will have ‘ripple effect’ to other systems. • Quality and safety in health care are now understood to be a vitasl component of systems and how we think about the system • TQM, QI and the science of ‘process re-engineering’ have also emerged in response to and understanding systems thinking.

9. Which is most important? • Safety or quality?

10. Quality in health care • Long history – practitioners punished for poor outcomes • 19th century Florence Nightingale identified a positive correlation between nursing care and mortality • 1910 US established relationship between medical education and patient outcomes • establishment of licensing boards • Increased government regulation and funding

11. Organisational concerns • 1952 Joint Commission on Accreditation of Healthcare Organisations JCAHO • 1974 Australian Council of Health Care Standards ACHS • 2006 Australian Commission on Safety and Quality in Health Care Professional involvement various • Nursing involvement in quality assurance • Blumenthal, D 1996 Quality of care – what is it? The New England Journal of Medicine 12 891-894 • 1990s government involvement??

12. Government involvement driven by • Recognition market forces do not operate in the same way that they do for other goods and service • Consumers are vulnerable • The recognition of the relationship between quality and costs

13. Quality problems (Chassin 1998) • Overuse • Providing a service when its risk or harm exceeds its potential benefit • Underuse • Failure to provide a service when it would have produced favourable outcomes • Misuse • Avoidable complications of appropriate health care • Which of the above has prompted change?

14. Quality health care • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Institute of Medicine 1994 America’s health in transition: protecting and improving quality. Washington DC National Academy Press

15. Why is health care different? • Unique characteristics? • What are they?

16. CHARACTERISTICS OF SERVICES Rowley (1998) Intangibility in that their outputs cannot be measured in terms of their physical attributes. Perishability in that they cannot be stored, and excesscapacity cannot be claimed or inventoried. Inseparability first and then produced and consumed atone and the same time. Heterogeneity in that the service is likely to be different for each individual who receives it.

17. Dimensions of Quality • National Health Performance Framework (2001) to consolidate the various bodies of thought pertaining to the definition of quality in healthcare • Nine dimensions

18. Nine Dimensions

19. ACSQHC developed the National Safety and Quality Health Service (NSQHS) Standards to drive the implementation and use of safety and quality systems and improve the quality of health service provision in Australia.  

20. The standards also provide a nationally consistent statement of the level of care consumers should be able to expect from health services.

21. There are ten NSQHS Standards focusing on areas that are essential to improving patient safety and quality of care: • Governance for Safety and Quality in Health Service Organisations • Partnering with Consumers • Preventing and Controlling Healthcare Associated Infections • Medication Safety • Patient Identification and Procedure Matching • Clinical Handover • Blood and Blood Products • Preventing and Managing Pressure Injuries • Recognising and Responding to Clinical Deterioration in Acute Health Care • Preventing Falls and Harm from Falls

22. What does this mean in health? • How do we define value? • Are there different actors? • Perception and interpretation? • Private v’s Public?

23. CUSTOMERS, CONSUMERS, CLIENTS & PATIENTS • Users • who actually use the health care service. • Influencers • particularly those with previous experience with the service who may influence the users decisions. • Deciders • the actual decision makers in the use decision

24. Customers, Consumers, Clients & Patients • Approvers • who authorise the decision • Buyers • who have the formal authority to buy and act as gatekeepers for purchasing

25. Which Quality? • Managing health service quality is managing gap between expectation and perception of all concerned • Most important gap is of • Consumer expectation of service • Perception of service actually delivered

26. Which Quality? Consumers are influenced by • Own knowledge • Experience • Claims of owning organisation

27. Rowley (1998) identifies four key gaps to consider when defining quality of care: Gap 1: The understanding gap. • The difference between what consumers expect of the service and what management perceives consumers expect. Gap 2: The design gap. • The difference between what management perceives and the consumer expects and the quality specifications set for the service delivery.

28. Gap 3: The delivery gap. • The difference between the quality specifications set for service delivery and the actual quality of that service delivery. Gap 4: The communications gap. • The difference between the actual quality of service delivery and the quality of that service delivery as described in the organisation’s external communications.

29. Donabedian 1966 proposed an integrated paradigm of health care quality that identified and delineated three categories of interdependent quality determinants

31. Structure Process Outcome Material Procedures Methods Information People Skills Knowledge Training Equipment Products Services Information Documentation Process Outputs Inputs

32. Outcomes • Intended • Unintended? • How does quality address this?

33. Measurement of quality in health care • Why measure quality • Accountability • Demonstrate improvement

34. Requirements for measurement • Definition of quality • No generally agreed definitions • Different perspectives • Definition becomes political – the preference of the powerful group

35. Technical difficulties • Health care is a service • Access to data • Core business is professional practice – professional autonomy • Availability of the data – documentation, information systems • Cost of the data

36. Issues to be discussed • Quality is defined by the customer? • To improve output and outcomes we must improve the process? • Decisions and actions are improved when based on facts and data? • Most important resource? • Effective leadership? • What creates change in health care? • Continual improvement relies on continuous learning?