Take a look at most hospitals’ websites and you will see plenty of references to quality. The mission statement will often say something about providing quality care. There will often be a Director of a Quality on the board. This all rather begs the question what do we mean when we talk about quality in health care?
I’ve recently been awarded Generation Q Fellowship by the Health Foundation. This is an 18 to 24 month programme designed to develop leadership and quality improvement skills in people working in healthcare in the UK. I feel very privileged to have selected on to this programme.
At our first leadership forum we spent a few hours thinking about this question (if you are planning to improve something it strikes me as fundamental that we define what we are going to improve). At first we spoke about our current concerns for our own services. In my case, I am particularly interested in the safety and clinical outcomes of our services. I also care about how efficient these services are (I don’t think money should be a dirty word in healthcare). Later we were asked to put ourselves in the position of a patient or carer. It was really fascinating to look at the idea of quality from the point of view of patients or relatives. When we started to do this, I was struck by the fact that everyone in the room had personal experience of using the NHS, either directly or as a relative or carer. Sadly the experiences people reported were pretty poor. Waiting, poor communication and disjointed care were strong themes in all these stories. When we looked at quality from a patient’s perspective we came up with rather different ideas. Ease of access to healthcare was rated very strongly, as was patient-centredness. As a patient or carer we all assumed that the service was safe and effective. At the point of using healthcare, no one questioned the efficiency of these services. We also spoke about how the assessment of the quality of healthcare is context specific. For example, Patient centredness was deemed to be extremely important for someone with a long-term condition, but much less so during the treatment of a life threatening emergency.
The Insitute of Medicine in the USA has recognised the multifaceted nature of quality in healthcare. The IoM suggests that quality of healthcare systems should be assessed and improved across these 6 dimensions:
So how does this help us design and improve healthcare systems?
Well, I would argue that this demonstrates that we need to have multiple perspectives to assess the quality of a health system. Our work locally to develop a new healthcare system in Shropshire (FutureFit) has deliberately involved a wide variety of people from the start. We also need multiple measures, one single measure cannot possibly measure quality. Indeed an narrow focus on any one element such as access times is likely to reduce quality in other dimensions. Policy makers (and all those divorced from the frontline of patient care) would do well to ensure that they measure quality using a range of methods and, dare I say it, not try to force improvement by using the blunt instrument of targets.