Introduction
Today
in all areas of health care applications the attention is on the measurability
and comparability of results. Administrators have become more aware of the need
for information for policy formulation, implementation and monitoring (WHO
1996!). Without sufficient and quality data, without effective and proper use of
data, and without properly trained personnel, this measurability and
comparability cannot be implemented. Where information is available in the
health care services, it is often geared only to the allocation of resources and
the control of spending, not the need to evaluate services and patients outcomes
(WHO 1996). Systems have not been developed to evaluate the quality of health
care.
In
general, quality of health care issues have been defined as the absence or
shortage of financial, material, and human inputs (De Geyndt 1995). However,
not only is there a need to know the inputs that go into the care, there is a
need for the evaluation of the quality of care. This has not previously been
done because it was thought too difficult and costly. De Geyndt in his paper
made the statement:
“Outcome
measures were not used in the developing country studies. Improving outcomes
is a presumptive result of improving the process and is not documented mainly
for lack of valid and reliable measuring tools and indicators, the expense
involved and the tenuous cause-effect relationship between process and outcome
(De Geyndt)
If
the information is not collected, the costs and sufferings in the long run
will be even greater.
There
are good reasons to focus on the processes in health care instead of only the
inputs. Willy De Geyndt in a World Bank Technical Paper on
Managing the Quality of Health Care in Developing Countries listed
specific objectives and the rational for the measuring of health care quality.
Summaries of these are:
-
Comply
with social commitments by providing self-regulation and self-correction
efforts to assess and improve performance.
-
Enhance
efficiency in using existing resources in all countries and containing the
cost spiral in some countries. Protect the health of the public through less
individual variations among physicians in the use of diagnostic and
therapeutic procedures, the appropriate introduction, diffusion and use of
new technology, reduction in medically unnecessary procedures, and applying
effective public health measures.
-
Monitor
the quality of the services provided to the patients.
-
Forms
the basis for research, provides the teaching materials for continuing
education of health care professionals.
-
Make
access to good quality health care more equitable.
-
Proving
for accountability from health care providers.
As
epidemiological patterns shift there is a need to place greater emphasis on the
types of diseases emerging.
In the
USA, the Joint Commission on Accreditation of Hospitals listed the steps to
provide for this quality of care. The following are nine of the steps:
-
Assign
responsibility
-
Delineate
scope of care or service
-
Identify
important aspects of care or service
-
Identify
indicators
-
Establish
thresholds for evaluation
-
Collect
and organize data
-
Evaluate
care when the thresholds for evaluation are reached
-
Take
appropriate actions
-
Assess
the effectiveness of the actions and communicate the findings to the
organization's
quality assurance program.
The New England Journal of Medicine concluded in a series of articles that
healthcare quality can only be achieved by capturing detailed clinical (Blumenthal,
D., 1996)
Present Systems
The
existing methods of quality determination are neither effective or sufficient.
These costly subjective valuations are generally based on either interviews,
surveys, or observations performed infrequency over a limited number of cases.
Once this limited "research" is done, results are often presented in
statistical form unusable by local management.
provider interviews generally do not provide reliable data about
what providers do, and record reviews (based on patient registers) furnish
very limited information. In addition, providers are not very consistent in
their management of individual patients, implying that a single observation
would not be sufficient to draw reliable conclusions (Franco,
Franco, et al 1996)
While direct observation may be considered the gold standard for the
measure of "true" performance of the health worker in a one time
study [the focus of most research], it is impossible to use direct observation methods to either collect sufficient information or be
able to use it for Management. Because of the complexities of health care, one
supervisor cannot assimilate the information required for management of his
staff through
direct observations. Clients do not generally present with only one syndrome
but rather a multitude of concerns. Clients are generally not seem by only one
staff but rather several different ones at several different locations
depending on the problem. In order for a manager to manager he must be able to
make sense out of this complexity. He needs data from all areas of care, he needs lots
of it, and he needs it continuously. Treating each occasion [as present
evaluation projects evaluation] does not make it, management must be in for
the long term. For quality care, management must treat the client over his or
her lifetime.
Many "Research" projects even go so far as to attempt to assign a
cost to the "Assessment of Quality." This is ridiculous; quality
care should be a regular feature of health care. It is not a separate function
and is not independent of management.
The information that is required to managed quality of care is required in
depth and continuously. In is NOT ENOUGH to collect Indicators that are
"intended to be sufficiently concise and practical that it can be
repeated every 1-2 years to track progress in improving quality of care in a
given set of facilities." Although this type of analysis may be sufficient
for spot checks by researchers, the concern is that the local managers may
believe that this is the only thing that must be "managed" and that
it is sufficient for him to prepare for this "outside" nuisance
"once every 1 or 2 years."
Data also should be able to be used by a manager. It should NOT be so
difficult to interpret that "While a few of the above mentioned scenarios
are self-explanatory, most require consultation with a trained statistician who is familiar with the
concepts of sampling."
...And Just Who are we collecting this information
for?
Discussion
Quality
of Care is a complex term and has different meaning to different stakeholders at
different times. Any comprehensive analysis of the Quality of Care requires
hundreds of indicators from multi-systems across time and space.
Because of
this complexity it is impossible to design a simple system that will provide
the information that is needed for management and to provide Quality of Care.
In the past, as discussed in the preceding paragraph, it was not possible to analyze
Quality of Care. Today, with Clinical Information Systems it is possible not
only to analyze health care procedures but also to manage them, and to
provide evidence based research based on the data that it obtain.
Links and Downloads
Agency for Healthcare
Research and Quality
International Society for Quality in Health Care.
ISQua, The International Society for Quality in Health
Care, is a non-profit, independent organisation with members in over 70
countries. ISQua works to provide services to guide health professionals,
providers, researchers, agencies, policy makers and consumers, to achieve
excellence in healthcare delivery to all people, and to continuously improve the
quality and safety of care. Their Mission is continual improvement in the
quality and safety of health care worldwide through education, research,
collaboration and the dissemination of evidence-based knowledge.
USAID Quality Assurance
Project (QAP). The Quality Assurance Project (QAP)
was initiated in 1990 to develop and implement sustainable approaches for
improving the quality of health care in less developed countries. QAP has two
broad objectives: 1) to provide technical assistance in designing and
implementing effective strategies for monitoring quality and correcting
systemic deficiencies; and 2) to refine existing methods for ensuring optimal
quality health care through an applied research program. The Quality Assurance
Project is funded by the U.S. Agency for International Development under
Cooperative Agreement DPE-5992-A-00-0050-00 with the Center for Human
Services. Collaborating with the Center for Human Services on this project are
the Johns Hopkins University School of Hygiene and Public Health and the
Academy for Educational Development. | 
