What on earth is quality?

by TheEditor

Categories: Investigative, Medicine

Quality is a multifaceted concept that can differ greatly depending on the context, product, or service in question. There isn’t a universal set of quality components that apply equally to every single product or service, but there are common elements that many quality evaluation systems tend to consider.[AC_PRO id=913]

Key aspects of quality

I outline some of the key aspects that often factor into the quality of both products and services.

  1. Performance: This is perhaps the most basic element of quality. It addresses how well the product or service performs its intended function. For instance, a high-quality phone will have fast processing times, an excellent camera, long battery life, etc.
  2. Reliability: This considers how consistently a product or service performs over time. A high-quality product is reliable and doesn’t fail unexpectedly. Similarly, a high-quality service is dependable and provides consistent results.
  3. Durability: This is the capacity of the product to maintain its functionality over a long period. Durability often ties into the physical robustness of a product or the longevity of a service.
  4. Features: These are additional characteristics or functionalities that enhance a product or service. They’re not always essential to the basic function but can significantly enhance perceived quality.
  5. Conformance to standards: High-quality products and services adhere to relevant standards and regulations, which might be safety standards, environmental standards, industry-specific standards, etc.
  6. Design: This relates to how the product or service has been crafted. A well-designed product or service doesn’t only look good but also feels intuitive and easy to use.
  7. Customer satisfaction: Ultimately, a high-quality product or service is one that meets or exceeds customer expectations. This is why It is essential to understand your target market and their needs and wants.
  8. Value for Money: This considers the balance between the cost of the product or service and the benefits it offers. It doesn’t mean the cheapest, but it does mean that the consumer feels they are getting their money’s worth.
  9. Serviceability: If something goes wrong with a product or service, can the issue be resolved quickly and effectively? High-quality products and services usually come with excellent customer service and warranties.
  10. Sustainability: In a world increasingly concerned with environmental impact, many people also consider a product or service’s sustainability when evaluating its quality.

These are some broad aspects, and the relevance of each may vary from product to product, service to service. Also, as societal norms change, these quality components may evolve too.

Possible patient perspectives

Patients using the UK’s National Health Service (NHS) are likely to assess the quality of the service based on several dimensions. While every patient might prioritise different elements depending on their individual needs and experiences, the following aspects are often important in evaluating healthcare quality:

  1. Effectiveness of Care: Patients expect the treatment they receive to be effective, addressing their health concerns and leading to improved health outcomes. This includes correct diagnosis, appropriate and effective treatment, and preventive measures.
  2. Safety: Healthcare services should not result in harm to the patient. Safety in the NHS might be assessed in terms of cleanliness of facilities, how well infection control is maintained, and the accuracy of medical procedures and medication dispensing.
  3. Patient-Centredness: The degree to which care is tailored to the individual needs of the patient is important. This involves respect for the patient’s values and preferences, clear communication, emotional support, and involvement of the patient in decision-making about their care.
  4. Timeliness of Service: In healthcare, delays can significantly impact patient outcomes and satisfaction. Patients might evaluate the wait times for appointments, treatment, and surgeries, and the speed of response to queries or concerns.
  5. Efficiency: Patients might assess the NHS on its ability to provide care without wasting time or resources. This could involve the smoothness of the referral process, the availability of appointments, and the adequacy of follow-up care.
  6. Equity: Patients may evaluate whether care is provided equally to all patients, regardless of their backgrounds. Equity in healthcare means that everyone has a fair opportunity to attain their full health potential.
  7. Accessibility: The extent to which healthcare services are provided without financial, geographical, or cultural barriers is another important dimension of quality. This includes being able to access necessary care regardless of location or financial situation.
  8. Communication: Good communication is crucial in healthcare. Patients value clear, comprehensible information about their health, the treatments they are receiving, and any other concerns they might have.
  9. Compassion and Respect: Patients want to be treated with dignity, kindness, and respect. They also value empathy and understanding from healthcare professionals.
  10. Coordinated Care: Especially for patients with multiple health conditions, the extent to which different healthcare services (like GP services, hospital services, community care) work together to provide coordinated care can be a crucial quality indicator.

Regulatory bodies like the Care Quality Commission (CQC) in the UK set out standards that healthcare providers must meet. These standards are in line with the aspects discussed above and aim to ensure high-quality, safe, effective, and compassionate care.

Areas of dissatisfaction

Patient experiences can vary greatly, and what displeases one patient may not be an issue for another. Health services often use surveys and other feedback tools to understand their patients’ experiences and identify areas for improvement. Several factors can lead to patient dissatisfaction with health services. Some of the most common sources of displeasure include:

  1. Long Wait Times: This is often one of the top complaints from patients. Whether It is waiting for an appointment, in the waiting room, for test results, or for treatment to begin, patients generally expect and value timely care.
  2. Poor Communication: Inadequate or unclear communication from healthcare providers can lead to significant dissatisfaction. This could be about diagnoses, treatment plans, medication instructions, or general lack of information sharing.
  3. Inadequate Time with Health Professionals: Patients can feel rushed during appointments if healthcare providers do not spend enough time explaining diagnoses, treatments, and answering questions.
  4. Disrespectful Treatment: Patients expect to be treated with respect and dignity. Any form of disrespectful behaviour, including not being listened to, can lead to a poor perception of service quality.
  5. Poor Coordination of Care: This can be especially frustrating for patients with multiple health conditions who require care from different providers. Poor coordination can lead to unmet care needs, repeated tests, or conflicting treatment plans.
  6. Lack of Involvement in Decision Making: Patients want to be involved in decisions about their care and treatment. When this doesn’t happen, it can lead to dissatisfaction.
  7. Accessibility Issues: Difficulty in accessing services, such as due to limited availability of appointments, long travel distances, or inadequate provision for patients with disabilities, can cause dissatisfaction.
  8. Poor Facility Cleanliness: Clean, well-maintained facilities are important for patient satisfaction. Poorly maintained facilities may lead to perceptions of poor service quality.
  9. Lack of Continuity of Care: Patients often prefer seeing the same doctor or healthcare provider over time. This helps build trust, ensures the provider knows their medical history well, and leads to more personalised care.

Subjective-objective gap

The subjective nature of many aspects of quality and satisfaction can pose challenges when trying to measure and improve them. However, there are ways to connect subjective feelings with more objective measures:

  1. Standardised Surveys and Questionnaires: Standardised patient satisfaction surveys like the Patient Satisfaction Questionnaire (PSQ-18) or tools like the Consumer Assessment of Healthcare Providers and Systems (CAHPS) in the US provide structured ways to capture patients’ perceptions of care. These tools use validated, standardised questions, which can be scored to provide quantitative measures of aspects that are essentially subjective.
  2. Experience-based Co-design: This approach involves working with patients to understand their experiences and identify what matters most to them. Through narratives and touch-point analysis, subjective feelings can be associated with specific aspects of service delivery.
  3. Patient-reported Outcome Measures (PROMs) and Patient-reported Experience Measures (PREMs): PROMs capture the patient’s view of their health status or health-related quality of life. PREMs, on the other hand, focus on the patient’s experience with health care services. Both use standardised measures to quantify subjective experiences.
  4. Customer Journey Mapping: This technique allows healthcare providers to understand the patient’s experience from their perspective. By mapping out each stage of the patient’s journey, providers can identify what’s working well and what isn’t, and link subjective feelings to specific stages of service delivery.
  5. Quantitative Analysis of Qualitative Data: Tools like sentiment analysis can quantify subjective experiences. For instance, analysis of online reviews or free-text comments in surveys can provide quantifiable data on subjective aspects.
  6. Balancing Measures in Improvement Work: When making changes in healthcare settings, It is important to consider the potential impact on patient experience, even if the primary goal is more objective (like reducing waiting times).
  7. Training and Standards for Staff: Defining clear service standards and training staff in areas like communication skills can help ensure a more consistent service experience, reducing variation in subjective experiences.

While these methods can help connect subjective experiences to more objective measures, there’s inherent value in subjective feedback. The very fact that perceptions of quality and satisfaction can vary so much between individuals is a reminder of the importance of patient-centred care, and of tailoring healthcare services to meet the unique needs of each patient.

Penny-wise pound-foolish?

Maintaining and improving quality in the NHS, like in any healthcare system, certainly carries costs. These may include costs associated with hiring and training staff, implementing and maintaining quality assurance systems, conducting audits and evaluations, investing in infrastructure and technology, and more.

Some specific costs might include:

  1. Staffing Costs: This includes hiring more staff to manage increased patient loads and reduce wait times, investing in ongoing training for staff to ensure they are up-to-date with the latest practices, and implementing retention strategies to reduce staff turnover.
  2. Technology and Infrastructure: Costs associated with updating or replacing aging infrastructure, implementing new health IT systems, and ensuring interoperability between different systems.
  3. Quality Improvement Programs: Costs associated with implementing and maintaining these programs, which may include training, process changes, and more.
  4. Regulatory Compliance: Costs of complying with regulations and meeting standards set by regulatory bodies like the CQC.
  5. Patient Safety Measures: Costs associated with improving patient safety, such as infection prevention and control measures, safety training for staff, etc.

While these costs can be significant, it is crucial to note that the costs of not maintaining or improving quality can be even greater. Poor quality can lead to:

  1. Increased Healthcare Costs: Poor quality care often leads to increased healthcare costs down the line, as it can result in complications, readmissions, or prolonged hospital stays.
  2. Lost Productivity: When patients do not receive high-quality care, it can impact their ability to work or go about their daily lives, leading to lost productivity.
  3. Patient Dissatisfaction: Poor quality can lead to patient dissatisfaction, which in turn can impact a healthcare provider’s reputation and, potentially, their funding.
  4. Legal Costs: If poor quality care results in harm to a patient, it can lead to legal costs and potential financial settlements.
  5. Preventable Harm: Perhaps most importantly, poor quality care can lead to avoidable harm to patients, affecting their quality of life and even leading to premature death.

While it is difficult to put an exact figure on these costs, research consistently shows that the costs of poor quality care are substantial. It is generally agreed that investing in quality is not only the right thing to do for patients but also makes economic sense. it is more of an investment rather than a cost, given the potential savings and benefits associated with high-quality care.

Loss of quality

The Care Quality Commission (CQC) is an important regulatory body in the UK’s healthcare system, providing independent assessments of health and social care services. However, despite the presence of the CQC and its rigorous inspections, some health services may fall short of maintaining quality for several reasons:

  1. Complexity of Healthcare: Healthcare is a complex field with multiple interdependencies. Changes in one area (like staffing, funding, or patient demand) can have unexpected consequences elsewhere, leading to fluctuations in quality.
  2. Resource Constraints: Many healthcare providers operate under significant resource constraints, including limited budgets, staff shortages, or infrastructure gaps. In such situations, maintaining quality can be challenging.
  3. Organisational Culture: If a culture of continuous improvement, patient-centricity, and excellence is not fostered, organisations might become complacent or lack the motivation to maintain high standards.
  4. Frequency of Inspections: The CQC cannot inspect every facility constantly. While they strive to target their inspections where they will have the most impact, issues can arise between inspections.
  5. Rapid Change: Healthcare is a field that changes quickly due to technological advances, evolving best practices, demographic changes, etc. Sometimes organisations may struggle to keep up with these changes, leading to a dip in service quality.
  6. Measurement Challenges: As mentioned earlier, measuring quality can be challenging, especially for more subjective aspects of care. Some quality issues may not be easily identified through standard inspection processes.
  7. Variability in Patient Population: Different patient populations have different needs and expectations. A service that is high quality for one patient group may not be for another.
  8. Change Management Issues: Implementing changes in large, complex organisations is difficult. Even when issues are identified, there can be barriers to implementing improvements.
  9. Underreporting or Misreporting: There might be cases where issues are not accurately reported to the CQC due to fear of reprisal, stigma, or lack of awareness.

Despite these challenges, it is important to note that the CQC plays a vital role in the UK’s healthcare system. The vast majority of services meet or exceed the standards set by the CQC, and where issues are identified, they are often addressed rapidly. However, as with any system, there are opportunities for improvement, and learning from instances where quality falls short is an important part of this.

Systemic issues and quality

While the National Health Service (NHS) in the UK is one of the most highly-regarded healthcare systems globally, it is not without its challenges. Some of the systemic issues that can impair the delivery of quality care include:

  1. Workforce Shortages: The NHS has faced long-standing staffing shortages in various areas, including nursing and general practice. Workforce shortages can lead to increased workload for existing staff, longer waiting times for patients, and potential compromises in care quality.
  2. Funding Constraints: The NHS operates under tight budget constraints, which can limit its ability to expand services, invest in new technologies, and recruit and retain staff. This can also impact the quality of care delivered.
  3. Increasing Demand: The demand for NHS services is increasing due to factors like an aging population, increasing prevalence of chronic diseases, and higher patient expectations. This can place strain on services and potentially impact quality.
  4. Health Inequalities: Health outcomes and access to services can vary significantly across different population groups and geographical areas in the UK. These inequalities can lead to variations in care quality.
  5. Interoperability of Health IT Systems: While significant progress has been made, there can still be challenges with the interoperability of different health IT systems in the NHS. This can hinder the coordination of care and lead to inefficiencies.
  6. Organisational and Structural Changes: The structure of the NHS has undergone various changes over the years, which can lead to uncertainties and transitional challenges that could impact service delivery and quality.
  7. Cultural Issues: Issues related to organisational culture, such as poor leadership, lack of staff engagement, or lack of a patient-centred approach, can also impact the quality of care.
  8. Pandemic Preparedness and Response: The COVID-19 pandemic has highlighted some systemic issues in the NHS, including the capacity to manage surges in demand, the need for robust infection prevention and control measures, and the mental and physical wellbeing of the workforce.
  9. Infrastructure: Aging infrastructure and equipment can sometimes limit the ability to provide high-quality care. This includes both medical equipment and facilities.

Addressing these systemic issues often requires a combination of policy changes, increased funding, workforce planning, technological advancements, and cultural shifts. The NHS continually works towards identifying and rectifying these issues to enhance the quality of care delivered to patients.

Inquiries and reviews

Inquiries play a vital role in understanding, maintaining, and improving the quality of healthcare services. These are often conducted in response to specific incidents, concerns, or areas of perceived weakness, and they can provide deep insights into the functioning of the healthcare system. The role of inquiries in quality feedback can be understood as follows:

  1. Investigating Failures and Incidents: When a significant incident or failure occurs, an inquiry helps to establish what went wrong, why it went wrong, and what could be done to prevent a recurrence. Examples include the Mid Staffordshire NHS Foundation Trust Public Inquiry in the UK.
  2. Identifying Systemic Issues: Inquiries can reveal systemic problems that might not be apparent from looking at individual incidents or local issues. They can highlight structural, organisational, cultural, or regulatory issues that are affecting quality.
  3. Learning Lessons: One of the primary goals of an inquiry is to learn lessons that can be applied to improve future practice. By understanding what went wrong and why, the healthcare system can change to avoid similar issues in the future.
  4. Providing Accountability: Inquiries help to hold healthcare providers and systems accountable for their performance. They can help to ensure that failures are recognised, and appropriate action is taken.
  5. Influencing Policy: The findings of inquiries can influence health policy at a local and national level. This could involve changes to regulations, increased funding for certain areas, changes to training or practice, etc.
  6. Engaging Stakeholders: Inquiries often involve engagement with a wide range of stakeholders, including patients, healthcare providers, policymakers, and the public. This can help to ensure that a wide range of perspectives are considered and that the lessons learned are relevant and actionable.
  7. Improving Transparency: By investigating and reporting on healthcare quality, inquiries can improve transparency, increasing public confidence and trust in the healthcare system.

While inquiries are an important tool for learning from failures and improving healthcare quality, they are just one part of a larger system of quality assurance and improvement. They need to be complemented by ongoing monitoring, evaluation, and quality improvement activities.

The Ockenden review

The Ockenden review, an independent investigation into maternity services at the Shrewsbury and Telford Hospital NHS Trust in the UK, found significant failures in care, governance, leadership, and staffing. Initiated in 2017, the review examined nearly 1,500 cases from 2000 to 2019.  I attempt to summarise the report below as a prime example of how well known standards that were meant to assure quality, were not delivered. The themes extracted could equally apply to many failing Trusts around the country:

  1. Failure in Care: The review found repeated errors in care leading to injury to either mothers or their babies. There were significant or major concerns in the maternity care provided in one in four cases of stillbirth, two-thirds of cases of Hypoxic Ischaemic Encephalopathy (HIE), and nearly a third of all neonatal deaths reviewed.
  2. Failure in Governance and Leadership: The review found that the trust leadership team up to board level was in a constant state of change and failed to foster a positive environment to support and encourage service improvement at all levels. The trust board did not have oversight or a full understanding of issues and concerns within the maternity service.
  3. Poor Working Relationships: There was a culture of ‘them and us’ between the midwifery and obstetric staff, which engendered fear among midwives to escalate concerns to consultants. This lack of psychological safety in the workplace limited the ability of the service to make positive changes.
  4. Lack of Compassion: Parents repeatedly reported a lack of compassion expressed by staff, either while they were still receiving care or in follow-up appointments and during complaints processes.
  5. Staffing and Training Gaps: The review found significant staffing and training gaps within both the midwifery and medical workforce that negatively affected the operational running of the service.
  6. Lack of timely action: There were failures to investigate matters in a timely way and learn lessons.

None of the above are new themes among Trusts that have failed or are failing.

Closing summary

  1. Quality in healthcare is a multifaceted and complex concept, consisting of various elements such as safety, effectiveness, timeliness, efficiency, equity, and patient-centredness. Understanding these components and their interplay is critical to assessing and improving the quality of care.
  2. In the context of the UK’s NHS, quality assessment involves several regulatory bodies like the Care Quality Commission, NHS Improvement, Clinical Commissioning Groups, and others, which monitor performance, provide guidance, and hold services accountable.
  3. Despite these quality assurance measures, sometimes, healthcare services may fall short of quality standards due to issues such as the complexity of healthcare, resource constraints, organisational culture, frequency of inspections, and other factors.
  4. Additionally, systemic issues often pose challenges to maintaining and improving quality within the NHS. These include workforce shortages, funding constraints, increasing demand, health inequalities, interoperability of Health IT systems, organisational and structural changes, cultural issues, and more.
  5. Inquiries into specific incidents or systemic issues in the healthcare system play a vital role in learning from failures and enhancing quality. They can provide deep insights, influence policy, and help drive improvement while promoting accountability and transparency.
  6. Maintaining and improving quality in the NHS does involve significant costs, such as staffing, technology and infrastructure, quality improvement programs, regulatory compliance, and patient safety measures. However, the costs of not maintaining or improving quality can be even greater, leading to increased healthcare costs, lost productivity, patient dissatisfaction, legal costs, and preventable harm to patients.
  7. Investing in quality, therefore, is both a moral imperative and an economic one. Despite the challenges, the NHS continues its effort to provide high-quality, safe, and effective care for all patients, learning from failures and continuously striving for improvement.
  8. There are few new themes among NHS Trusts that have failed or are failing.

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