QA-ing QA

Citation

Hurst, K. (2014), "QA-ing QA", International Journal of Health Care Quality Assurance, Vol. 27 No. 4. https://doi.org/10.1108/IJHCQA-11-2013-0137

QA-ing QA

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 27, Issue 4

Are patient outcomes and service outputs improved when people use our health service? Not a ridiculous question; i.e. many UK patients undergoing varicose vein surgery report a lower quality of life, while knee-joint replacement patients indicated a significant improvement after treatment. Quality improvement (QI) and assurance (QA) projects are unknown territories, costly and evaluating whether they work (i.e. monitoring the monitoring) is an additional significant cost. So, establishing the right QA evaluation methods is worth time, effort and money. Yoku Shaw-Taylor's paper underlines key points about QA's nature, utility and value, and what known and unknown impact they have on patients and services. Dr Shaw-Taylors’ evaluation identifies why expensive, US QA programmes might be failing and recommends ways to plug the gaps and ensure that maximum value is obtained from QI initiatives.

Ali Mohammad Mosadeghrad, in a similar vein, looks at total quality management's (TQM's) ability to improve health service quality and concludes (in Iran at least) that TQM, an expensive undertaking, may not be value for money. Professor Mosadeghrad presents sobering evidence, straight from the horse's mouth; i.e. the healthcare staff, expected to work with TQM processes, said that TQM may not be value for money before pointing to clear reasons why TQM falls down and how it can be improved. TQM investment means the programmes can’t be written-off, so the author suggests how service managers can obtain the most from their TQM programmes.

Health services around the world are data rich but information poor. Sometimes we can’t see the wood for the trees and we overlook valuable data, which could be synthesised to generate new insights. Yoku Shaw-Taylor's paper (précised above) strongly indicates that missing and incoherent data could be reasons why we fail to show that QA programmes work. However, simply identifying missing data and constructing systems to gather and process them may open Pandora's box. Professor Carolyn Berry and colleagues, in this issue, for example explore problems and pitfalls surrounding race and ethnicity data collection, notably Latino patients’ (possibly fearing extradition) suspicions about why more detailed ethnicity information was needed. However, staff perseverance and robust data collection protocols in a large-scale project that Professor Berry describes, overcame most problems and managed to improve services by enriching already useful information.

Sedating elderly, mobility-impaired and other high-risk patients at night in poorly supervised wards is recipe for disaster; i.e. disoriented patients, waking from a drug-induced sleep, with a full bladder, may fall during their search for toilets, risking fractures and head injury. Inpatient sedation and hypnotic prescribing frequency may surprise many who read Olwen Murphy and colleagues’ simple but effective evaluation paper in this issue. The research team grasped the sedation prescribing nettle by focusing on clinicians’ documented rationales for prescribing sedatives and hypnotics. They found that many medical records were lacking meaningful reasons for prescribing these medications, among other practice shortcomings. Consequently, the authors are creating best-practice prescribing protocols in their hospital.

Healthcare hasn’t escaped the austerity packages that government ministers were forced to introduce in the last decade. Healthcare staffing, the biggest health service cost component, understandably took the brunt. As we saw in recent UK healthcare service quality scandals, shrinking clinical teams (i.e. not filling vacancies) or diluting the workforce with support staff rather than registered practitioners meant that North Staffordshire Hospital patients (for example) paid a heavy price (higher death rates). Consequently, Niamh Humphries and colleagues, in this issue, place professional burnout (caused by overwork and understaffing) under the spotlight, a topic, they discovered that hasn’t undergone systematic review. They synthesise evidence from several publications to highlight that poor retention, high staff-turnover and staff shortages are a vicious cycle that results in professional burnout among the dedicated and conscientious staff who stay and its effects on the service quality they try to maintain.

If staffing levels are reasonable and there are enough registered nurses (RNs) in the staff mix then extending RN roles by giving them specialist knowledge and skills, for example, can have a remarkable impact on ophthalmic service efficiency and effectiveness. Petrina Tan and colleagues evaluated cataract patients’ early discharge and substituting next-day outpatient post-operative review with patient education and nurse-administered telephone survey. Only one patient had to be recalled owing to complications detected by the telephone review. Elderly patients, living alone, with temporary visual impairments, not having to travel to the OPD for clinical review exudes service efficiency and effectiveness – a win-win situation.

Emergency department (ED) staff, especially when primary care out-of-hours services are below par, become the first port of call for patients who aren’t in emergencies or injured. EDs were renamed in the UK because their former title – Accident and Emergency Departments, or A&Es – became short for “anything and everything”. Despite educating the public about inappropriate ED attendances, creating healthcare telephone help lines and website services, ED attendances climbed relentlessly. Understandably, therefore, ED service efficiency and effectiveness studies are gaining popularity among IJHCQA's authors and readers. Kim and colleagues in this issue, for example, examine ways to improve children's ED services. They simulate process flow and control management data to improve ED throughput, shorten stays, reduce left-without-being-seen cases and shorten waiting time data under different scenarios. Dividing EDs into children and adult departments appears to make a difference; possibly improving service quality and patient satisfaction.

Reviewing other hospital services, accreditation assessors often say, has an unintended consequence – educational benefit gained from observing how well (and badly) healthcare is practised elsewhere. So why not formalise the process for mutual benefit? This is what Carolina Leike de Kort and colleagues attempt on a large scale in this issue. An international collaboration between US and the Netherlands research teams compared structures, processes and outcomes in the same specialist service (diabetic retinopathy) in two countries. Expectations were that same-speciality health services in two affluent countries would be broadly similar. However, there were significant procedural and outcome differences which were, it transpires, context sensitive that help clinicians, providing the same services, gain a different perspective on their own services. The authors underline their work's educational value but warn that comparing outcomes from the same service in different countries requires caution.

Keith Hurst