Leading-edge quality assurance activity

Citation

Hurst, K. (2009), "Leading-edge quality assurance activity", International Journal of Health Care Quality Assurance, Vol. 22 No. 4. https://doi.org/10.1108/ijhcqa.2009.06222daa.001

Leading-edge quality assurance activity

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 22, Issue 4

Editorial work has a major advantage – we get to see frontier QA work long before these important articles appear in print. Issues 22,2 and 22,4, for example, include an array of stalwart and virgin territories.

It’s always a heart-sink moment when strenuous quality assurance research and development efforts result in poor response rates. But even when we get reasonable replies, how can we be sure that valuable and important respondent groups’ views haven’t been missed? We published a Mayo Clinic patient personality characteristics and satisfaction report in IJHCQA 21,1, and we saw in Nesreen and Albedaiwi’s (21,7) article that male and female patient satisfaction study respondents answer differently. In 22,2, therefore, we’re pleased to publish a second article from the Mayo Clinic team in which Tom McLeod and his colleagues examined patient satisfaction questionnaire responder and non-responder characteristics from new angles. The authors provide valuable insights into why people with certain personality traits are less likely to respond. Moreover, we’re told about ways of appealing to non-responders. Clearly, there’s much to learn and do regarding patient satisfaction surveys and these studies are likely to remain on the QA bow wave.

Health service employee perceptions, in contrast, aren’t well studied. Arttu Saarinen and his Finnish researcher colleagues, however, report a nationwide study comparing young and old physician health service perceptions with general population cohorts. It seems that younger physicians hold different public service views possibly because their upbringing in post-war welfare systems cause them to see things differently than their older physician colleagues. Finland, like most European countries, experienced several public service changes in the last 50 years including privatisation. Younger physicians it seems are more open to new health service delivery systems, but more surprisingly, are hard-nosed about soft welfare systems. In short, we can get mileage from these empirical studies especially if they incorporate robust evidence from patient and professional health service perception studies.

The number of UK and US patients experiencing risky safety incidents is estimated to be one in ten so Karin Pukk Härenstam and her colleagues recently undertook a national survey exploring patient safety issues. They examined health service leaders’ safety perceptions, the first study of its kind in Sweden, involving 1,130 healthcare leaders. Our Patient Safety special issue in IJHCQA 21,1 showed that patient safety remained a thinly researched topic so readers won’t be surprised about the popularity of large-scale patient safety studies in view of the topic’s high-ranking position on the QA agenda. Readers may be surprised, on the other hand, about the range of views held by practitioner-manager respondents, especially any sub-groups’ diverse views. In short, leaders are realistic about meeting patient safety challenges and remain optimistic that safety can be improved. Their suggestions for monitoring and strengthening patient safety are impressive, which help Sweden’s policy makers implement patient safety structures and process and improve outcomes and outputs. Authors submitting to IJHCQA know that we actively encourage writers to describe methodological issues for their educational value. Karin and her colleagues not only met the editors’ expectations, but also introduce novel validity and reliability techniques that benefit other QA researchers. So, we can report that both substantive and QA methodological issue articles are racing towards the finishing line.

Health services tend to be data rich but information poor organisations, so specialist software that helps staff make sense of patients’ expectation and satisfaction is welcome. Sandra Liu and Jie Chen described a relatively new approach to healthcare quality assurance in 22,2. They applied data mining software to highlight patient preferences contextualised in their demographic and socio-economic backgrounds using information that may otherwise be hidden. They described commercial data mining software (and there’s a choice), which the authors found easier to use than traditional data reduction programs such as cluster analysis. Data mining software is used to group and analyse variables and related data. It helps users to manipulate large data chunks quickly and easily. Consequently, three significant clusters emerge from Liu and Chen’s large-scale US patient preference study. For example, black and minority ethnic group preferences were different to their white counterparts. In short, data mining tools profile patients, their preferences and ultimately highlight service implications. These outcomes are excellent for market analysis such as patient profiling and service development.

Tudor-Hart’s (1971) 40 year-old inverse care law (those with the greatest demand receive fewer resources) survives and healthcare inequalities seem to be an intractable problem. Socio-economic impact on service delivery and uptake remains an important research and development topic. In 22.2 we published Ronit Endevelt et al’s large-scale (1.35 million patients) Israeli healthcare inequalities study. Authors were able to access a large numbers of electronic patient records, filter patients with diabetes mellitus and focus on patients’ knowledge, demand and service uptake. The authors confirmed that deprived area residents are less likely to undergo diabetes screening and once diagnosed, less likely to receive nutritional advice even though incidence is greater and these populations and that they have more health risk behaviours such as smoking and poor diet. The authors underlined that deprived area residents with diabetes are sicker, less knowledgeable about diabetes and receive less attention. However, nothing’s straightforward; they show service uptake is also influenced by age and compliance with treatment and care. Nevertheless, their study helps us to spot points along the socio-economic continuum at which healthcare professionals should intervene with early interventions, including improving patient assertiveness, empowerment communications skills.

Readers, who like me act as accreditation surveyors, know how demanding and hard work it is, and moreover, what rides on the accreditation team’s judgements. David Greenfield and his Australian colleagues look at these and related accreditation structure, process and outcomes – notably surveyor reliability (assessor consistency within and between surveys), which is known to vary not least because individual and team-based judgement change decision making. Their strong, qualitative triangulation research design enabled the researchers to dig deeply into accreditation process issues, using among things, interviewing assessors, accreditation agency staff and target organisation personnel. Six areas emerged, which if addressed, could be used to strengthen health service accreditation. For example, it seems sensible to develop assessor education and training curricula by drawing from these six areas.

Patient records and the data they contain have a significant role in QA initiatives such as accreditation. Sameer Kumar and his colleagues, therefore, described US healthcare service policy and practice developments that easily stymie QA activities. They explored the US Health Insurance Portability and Accountability Act’s (HIPAA) impact not only on healthcare provision but also healthcare research and development. They do this within a thorough and clear explanation about US healthcare’s state of play. It’s easy to be selfish about Data Protection barriers placed in front of healthcare researchers, but none of us likes the idea that our or family members’ medical information is accessible to strangers. Samaeer et al. include clear flow charts showing manual and electronic patient record structure and process strengths and weaknesses. Data protection mechanisms, therefore, particularly electronic patient records in web-based healthcare, especially as HMOs and PPOs get established, deserve the most stringent security structures and processes. The authors note that staff can easily abuse regulations, simply by failing to understand complex legislation. They offer solutions to improve the Act’s good intentions, which seemed to be marred by poor implementation.

Patient choice, access and related issues are rapidly climbing the health policy agenda. In 22.4 Sean Murphy and his colleagues underlined why. One would think that morbidity and evidence-based medicine drive treatment decisions. If not then wouldn’t access, choice and patient outcomes suffer? Questioning this logic, the authors explored demographic, socio-economic, geographical and other factors that influence treatment. They concentrate on hypertension, which surprisingly, despite its prevalence and potentially disabling effects, hasn’t been studied too well. Hypertension is also a good choice since treatment costs vary significantly. The authors showed from published work that personal, social, service infrastructure and geographical factors influence hypertension treatment and care. They found that disease management depends less on the patient’s condition than one might imagine. Ability to pay, for example, seems to influence decision-making. A bonus in this article is the authors’ analytical methods for exploring quality issues like these, including strengths and weaknesses.

Continuing and broadening service access, choice and inequality themes started in Sean Murphy et al.’s article, Brian Martin and his US colleagues look closely at provider-patient concordance, another important research area that seems to be overlooked. The authors underline the issue’s multifaceted nature in the literature and as they eloquently put it, ameliorating minority population disparities to improve all round health is important. Analysing patient-completed questionnaires, they compared patients treated by clinicians from the same race, gender and language with patients lacking these concordances with professionals treating them. Their findings conflict with evidence in the literature and they indicate that relationships are more complex than we might imagine. Nevertheless, language and communication emerge as a major issue – seemingly bearing greatly on service access and choice. Their findings may be unsurprising; in practical terms, we can imagine service process and outcome effects when patients talk to doctors who do not speak the same language let alone having different cultural beliefs. The authors neatly summarise their findings into: first contact; coordination; long-term care; and comprehensiveness, which offers the next researcher an excellent framework in which to place and study healthcare inequality. Clearly, the Murphy et al. and Martin et al. articles have important health policy and practice implications.

Revital Gross et al. wrote about managed care in IJHCQA, 21,3. In this issue they extend their managed care research and publication portfolio by focusing on an unusual but important subject in a managed care organisations (MCO) – physicians and nurses working together, which has efficiency and effectiveness implications in any health service. Traditional hierarchies (in which doctors dominate) are breaking down. Nurses are now more autonomous practitioners particularly among those caring for chronically-ill (what we now call long-term condition) patients, but extending nursing roles into traditional medical care generate mixed perceptions and reactions. Although patients seem to like it, there is a suspicion that devolving medical tasks to nurses is designed to save money. Despite MCO manager expectations that joint working, encouraged by care protocols, will happen, there are doubts that it does. So the authors surveyed more than 740 physicians and almost 1,400 patients to check if teamwork occurs in practice. Physicians were asked to describe their nurse colleagues’ actual work and what they’d like them to do. Patients, on the other hand, were asked about their main carers. The authors report an intriguing set of physician and patient perceptions, which varied remarkably in different locations. In short, physicians wanted more nurse involvement, which seemed not to be happening because patients reported seeing mostly physicians. The authors conclude that nurses seem to have a limited chronic disease patient care role even though physicians preferred a greater involvement. Consequently, the authors look at the reasons behind this incongruence before suggesting actions to rebalance the situation. Clearly, the situation is complex, challenging and important.

We’ve published considerable patient expectation and satisfaction material in recent issues, notably the topic’s complexities and inter-relationships. We find the subject so important that we published a 50,000-word patient satisfaction special issue (IJHCQA, 21,1). Unsurprisingly, new findings are emerging and accepted wisdom increasingly is being knocked on the head. In this issue, Aditi Naidu takes stock of past and recent patient expectation and satisfaction literature. Aditi’s patient satisfaction model, which emerges from the review, richly deserves its holistic label. In Bandura’s evidential quality terms, the material contributing to the review is lower level. Nevertheless, the article raises opportunities to empirically explore and even implement early findings.

Masood Badri and colleagues continue the search for a comprehensive patient expectation and satisfaction model. Interestingly, their model is built from United Arab Emirates (UAE) data, a country that is rapidly developing its health services including some impressive capital projects. Equally, UAE health service academics are developing impressive QA systems. Readers will like the authors’ innovative statistical techniques, which unpick healthcare QA elements and rebuild them into new models that offer different perspectives. For example, one intriguing association is the effect of bombarding patients with too much information on their service quality perceptions. Patient expectation and satisfaction remain complex, and while we’re steadily unravelling the tangled twine, it’s clear that we haven’t identified all the relationships and dimensions. Patient satisfaction remains a bread and butter QA issue.

Occasionally, articles written in the style of what Americans call op-ed’s have as much policy and practice impact as empirically-based reports. Husayn Al Mahdy’s Bangladeshi healthcare reform article is a good example not least because he takes a macro and micro perspective. It’s clear from his Bangladesh health policy and practice perspectives that healthcare QA can’t survive without solid infrastructure such as robust health service hierarchies and appropriate workforces. Bangladeshis need to overcome these challenges if the country’s politicians are to meet Alma-Ata requirements; the motivation being that economic survival depends on any country’s workforce that needs to be healthy. The author implores politicians to make better use of clinician knowledge and skills when planning and implementing health services. For example, he argues that practitioners could make significant workforce planning and development contributions. It stands close reasoning that there are no more appropriate people to decide ways of getting enough people with the right knowledge and skills in the right place at the right time at the right price – significant challenges for the country’s politicians. Two unusual but interesting notions in the article are “health tourism” and “doctor shopping”, which the author not only explains but also explores from different perspectives. Changing doctor implications and potential solutions are well addressed. Money, as one might suspect, is the root cause of problems addressed in the article. However, the author offers solutions that have merit and ‘legs’. In short, an insight and solution-rich article.

Denis Towill is a regular IJHCQA contributor on subjects related to NHS efficiency and effectiveness, notably supply chains. In this issue, Denis revisits Method Study – a forerunner to Business Process Re-engineering, Lean Thinking and related service improvement methods. Readers, like me, may be surprised to learn that Method Study is 100 years old, and has a sound pedigree. Most “saving time and saving motion” study articles underline health service inefficiency and yet processing mapping methods and reports seem to be on the back burner – possibly because working smarter not harder and related phrases are used ad-nausea. Denis describes five Method Study steps, and his industrial and health service illustrations offer useful reference materials for readers thinking about adopting Method Study for health service research and development. Finally, Denis’ prologue gives a fascinating insight into the book and film “Cheaper by the Dozen” and its connection to Method Study.

Finally, and continuing the leading-edge theme, we publish an article that raises up-and-coming healthcare issues as more and more healthcare managers turn to treatment spell-based funding (using diagnostic related or healthcare resource groups). Edward Britton and his surgeon colleagues take a close look at NHS England’s reimbursement system – Payment by Results (PbR), which depends heavily on accurate clinical coding. The authors compare dedicated clinical coder results with orthopaedic surgeon coding. The discrepancies between the two coder groups are not only financially worrying but also raise doubts about related research and development (R&D) accuracy. Clearly, clinicians make the best coders but administrative work like this isn’t the best use of their time, despite clinical coding accuracy implications. It seems that validity and reliability checks, standard R&D operating procedure, may need implementing more broadly.

I can’t argue that these 15 articles represent QA’s state-of-the-art, but they hint strongly at not only what’s behind us but also what’s ahead. Fundamental QA issues emerge such as access, equity, efficiency and effectiveness implying that our QA theory and model armoury doesn’t need overhauling. What’s also clear is that these issues are common to many countries. Finally, what’s also clear is that QA data collection and analysis methods are also evolving, keeping is on our toes.

Keith Hurst