Improving Quality Of Care Chap20 Flashcards
Total quality management (continuous quality improvement)
An approach to quality improvement that involves the commitment of all members of an organization to meeting the needs of its external and internal customers.
Spend a few minutes writing down all the interventions or approaches to ensuring and improving quality that you are aware of in your own country.
You may have included some of the following which are commonly used around the world: registration of professionals; accreditation of facilities; clinical audit; accreditation of training facilities; litigation for malpractice; financial incentives; inspectorates; inquiries.
What are the two frameworks used to distinguish between the different approaches.
1 Internal versus external. This considers where the approach is conducted. The possibilities extend from self-assessment or audit by individual clinicians (looking critically at their own performance in private, without anyone else involved) to national (or even international) approaches by external organizations such as governments or health insurance companies.
2 Reactive versus proactive. This considers when the approach is used. There are two possibilities. It may be reactive, that is, it occurs after poor quality has occurred or is suspected, such as an inquiry into why a particular patient had a poor outcome. Alternatively, it may be proactive, routinely assessing quality to detect any suboptimal care.
Who are the customers?
Obvious customers are the patients.
Internal customers are the other staff: staff who depend on the services of other staff (e.g. ward nurses depend on porters to move patients; doctors depend on staff in diagnostic departments to carry out tests). In this approach, quality is the responsibility of all staff, not just those employed to undertake quality improvement. It presupposes that there are clear and proper long term organizational goals which all staff are aware of and committed to.
What interventions are used?
they can be considered in six categories, each of which you will consider in the rest of this chapter:
• education
• feedback of information
• incentives
• administrative structures and processes
• regulation
• legislation.
Providing guidelines
It is now standard practice to issue guidelines in three forms: an extensive account providing background information and the evidence on which they are based; a shorter version for the relevant health care workers; and a very short version for patients that avoids jargon and non-essential technical detail.
‘utilization review’
Audit
The collection and provision of quantitative data on performance.
How are audits fed back?
The information may be fed back passively or actively. Passive feedback means the data are simply disseminated and it is left to the recipients to decide what action to take. Active dissemination involves additional activities. For example, providing primary care doctors with information on their prescribing habits may be accompanied by a visit from a pharmaceutical adviser to discuss any atypical performance.
Incentives
Incentives come in several forms. First, they may either be financial (such as extra pay for carrying out an activity) or sociobehavioural, that is, appealing to workers’ desire to be well regarded by their colleagues and peers. Second, incentives may be positive (rewarding good quality) or negative (penalizing poor quality).
Generally, professionals respond more to sociobehavioural incentives than financial ones.
As regards positive versus negative incentives, people tend to respond more to positive promises than the fear of negative consequences.
Administrative structures and processes
One of the commonest reasons why poor quality care occurs is the way services are organized within a provider (health centre, community nursing service, hospital). While such problems may be manifest in numerous ways, there are four broad ways of reorganizing:
• change the availability of a service (e.g. introduce a list of essential drugs or a hospital formulary to avoid misuse);
• change access to a service (e.g. requests for diagnostic tests must specify the clinical justification or permit primary care doctors to request tests directly rather than having to refer the patient to a specialist first);
• change staff responsibilities (e.g. let nurses take over blood pressure checks from doctors);
• pre-authorization and concurrent review (e.g. a surgeon has to get permission from the purchaser of the service (such as a social insurance fund) before operating).
How can external regulation be imposed?
External regulation may be imposed in five main ways:
1 Financial payment – through contracts that specify the quality of care required.
2 Accreditation – this can apply to training programmes (e.g. determining whether or not a provider is a suitable place for training nurses); or to providing services (e.g. determining whether or not certain surgical operations can be performed). Accreditation tends to focus on the inputs available, such as staffing levels and equipment. Seeking accreditation is usually voluntary and, therefore, optional.
3 Certification – in some countries a provider has to obtain governmental approval before it can acquire particular equipment, usually expensive high tech kit.
4 Licensure – in most (perhaps all) countries, clinical staff are not allowed to practise unless they have been licensed to do so by a professional regulatory body. As you know from Chapter 6, this fulfils one of the characteristics of a profession, that of self-regulation.
5 Inspection – which may be regular and routine or reactive when a serious adverse event has occurred.
What are the problems with regulation?
As regulation is both expensive and can antagonize those being regulated, these are approaches that should be used sparingly and only where it is essential (such as licensing professionals). The creation of resistance among the very people you hope to change may be counter-productive. One danger of regulation is that those being regulated can gain control over the regulating body. A classic example is medical associations in which some members of the profession regulate their colleagues. This depends on the regulators remaining detached and avoiding being unduly influenced by the colleagues they are assessing. There is the danger of those being regulated defining the criteria by which they will be assessed.
Whichever of the approaches described is adopted, quality improvement is more likely to be successful if:
- it has the support and involvement of the most respected opinion leaders in the area
- there is a sense of ownership by the participants
- participants recognize the need for change • the focus is on improving quality rather than reducing costs
- a combination of approaches is used
- the methods used are changed every so often to ensure persistence of the change.
Litigation.
Legal action taken by patients against health care providers for alleged malpractice.
