Essay: Measuring quality in healthcare

The 21st century is, among others, under the “quality chasm” in health care provision. (RAND Health) Alongside with various pieces of research on the topic, the inclusion of the quality essential health-care services among the targets for the third Sustainable Development Goal of the United Nations highlights the global dimension of the interest for the quality of the health care delivery. (United Nations , 2018) Given the increasing interest for efficient management, several conceptual models for analysing the quality of delivered health care were developed over the time.
In the second half of the past century Donabedian developed a model for evaluating the quality of health care based on three components: structure, process, and outcome. (Donabedian, 2005) The structure component measures the attributes of the health care service or of the health care provider (for example staff to patient ratios). The process component implies measuring the way that the health processes and the overall health system are working for accomplishing the desired health outcome (for example: if staff wash their hands or what is the typical process for receiving a certain medical examination). The outcome component refers to the measurements on the impact on the patient; it is the measurement of whether health care objectives were achieved (for example: reduced mortality or reduced emergency admissions). (ACT Academy )  According to the author, despite several limitations of the outcomes measures, they are the “ultimate validators” of the effectiveness and quality of the delivered health care. (Donabedian, 2005) In the same time, the process measures are vital for quality improvement as they are the indicators of whether are done the things that should be done. In other words, the desired health outcomes depend of the behaviours that the health systems or health organisations foster for ensuring the achievement of the formers. (ACT Academy )
Thereafter various measuring tools were developed. But despite the various frameworks for evaluation, the quality of health care delivery remains separated in silos, mainly due to the differences that exist across the national health care systems.  (Lucia Kossarova, 2015)
In a comprehensive analysis of health care organisations, Bate et al reached the conclusion that even though “each quality journey was unique”, there is are common challenges that these organisations had to tackle. So it was created a model of six core challenges encountered in their analysis of health care organisations’ activity of improving quality. A challenge is the structural one, namely organising, planning, and coordinating the processes behind the quality efforts. Another challenge is the political one, which comprises addressing and dealing with the politics required by the change surrounding any effort of improving quality. The third challenge identified is the cultural one: creating a value for quality that is shared among the members of the organisation, having them giving the same meaning to quality. Another challenge is the educational one, namely creating learning process es that support continuous improvement. The fifth challenge is the emotional one – creating engagement and motivation by linking the quality improvement with personal beliefs, sentiments and inner commitments. The last challenge is posed by the physical and technological aspects, namely designing the physical infrastructure and supporting technological systems that account for and sustain quality improvement efforts. When reunited, the identified challenges create a system accounting for the inner context (organisation size, structure, history of performance) as well as for the outer context (social&political environments, technological advances, market). (RAND Health)
In the Bulletin of the World Health Organisation, Hanefeld and colleagues bring into attention that the recognition of the multifaceted nature of the quality of care is critical. Perceptions on the quality of care are shaped by interconnected community, health system and individual factors. Moreover, quality of care cannot be understood fully without some appreciation of the social norms, relationships and values and trust within the communities and societies where it is provided. (Johanna Hanefeld, 2017) As also highlighted by the Bate et al in the RAND Health research, culture plays an important role in improving quality of health care. The shared meaning that individuals in the health system or health organisations give to the quality play an important role in designing health processes that meet the needs and preferences of patients.
As Donabedian’s work also shows, the achievement of the quality outcomes is mediated by the processes inside the health structures. This puts emphasis on the importance that health care professionals play in actually implementing the guidelines for quality improvement and monitoring. The meaning that health professionals give to the quality improvement and monitoring guidelines is a driving factor of the behaviours that these professionals exhibit in their daily practice.
A study by van Loon et al on the gaps between the development and implementation of the guidelines for diagnosis of problem behaviour in elderly care shows a case of successful use of guidelines as tools that offer structure but not a predefined answer. The authors argue that the guideline created three important changes: served as an important resource for improving the situation of the clients, offers coordination in the care process and changes the multidisciplinary collaboration, and gave them the tools to do something positive about client behaviour that was often annoying or difficult to cope with. Thus by being flexible enough, the guideline offered a structure for tackling an aspect of the quality of care but it also let enough space for professionals to account for the particularities of the situation. (Esther van Loon, 2014)
Levay and Waks argue that the soft autonomy is a suitable approach to increasing transparency and improve professionals’ relationship with the quality monitoring. They argue that even though professionals’ might be inclined to defend their professional autonomy against external scrutiny, their need of legitimising their work in face of the external demands motivates them to get involved in increasing transparency in healthcare. Their involvement is translated in two types of behaviours: the translation of guidelines and regulations in local context, and the negotiations and continuous discussions in the professional network for further advancing the existent criteria and procedures. (Charlotta Levay, 2009)
The findings of the QUASER (Quality and safety in European Union hospitals: A research-based guide for implementing best practice and a framework for assessing performance) project showed that, in spite of the different national and local contexts, common themes in how the selected hospitals approached quality improvement. Unfortunately, the main drivers were governance, compliance and accountability as opposed to learning and cultural change. The focus proved to be rather on tools and data than on changing behaviours and cultures. However, among the studied hospitals, also existed “pockets” where strategies were enacted contradicting the common features; for example, relating to cultural and educational challenges. The hospitals which were exceptions had a long-term commitment to quality and stable leadership which further led to the establishment of a track record of quality improvement. In these hospitals, leaders embedded quality in the culture, aligned quality and cost reduction goals and motivated and energised staff. (University College London, 2017)
On these accounts, quality improvement should no longer be only a matter of measuring and designing guidelines but it should also actively act on the elements inside the so-called “black box”. The professional culture and health care leadership are vital in making the qualitative of the health from an aim a daily reality of the health care practice.