Keith Hurst (Independent Research and Analysis, Mansfield, UK)

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Article publication date: 12 October 2015


Hurst, K. (2015), "Editorial", International Journal of Health Care Quality Assurance, Vol. 28 No. 8. https://doi.org/10.1108/IJHCQA-07-2015-0090



Emerald Group Publishing Limited


Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 28, Issue 8.

Quality assurance (QA) frameworks; their nature and value

In a former life (university lecturer), one task I asked post graduate students to complete during lectures on research and development (R&D) conceptual frameworks was to write a one-page essay that described how computers work. Unbeknown to the students, half were given that simple instruction. The other half answered the same question but were asked to frame their essay using the input (e.g. keyboard, scanner, microphone); processor (i.e. CPU) and output (e.g. monitor, printer, speakers) conceptual framework. One group marked the others' essays; i.e., each marker was asked to judge the essay's structure and content. The conceptual framework-based essays were always rated higher. Anecdotally, therefore, a conceptual/theoretical framework is a fundamental ingredient in empirical R&D and especially so in QA studies. How common and robust are QA frameworks and what evidence do we have about their systematic use? Theoretical/conceptual frameworks feature heavily in this issue.

Accreditation, especially by external peer review, is designed to correct and develop health services. In this issue, Melvin Kilsdonk and colleagues review current peer review accreditation systems and approaches. Their comprehensive literature review reveals systematic flaws, such as failing to base the accreditation/review in a theoretical/conceptual framework (e.g. Donabedian's structure, process and outcome triad), a flaw that needs correcting if healthcare services are to fully benefit from accreditation reviews. The fundamental flaw unearthed by the authors is surprising since the QA field is particularly well blessed with theories and models in which to think and act. Simply alerting QA specialists to a dying art may be sufficient although QA frameworks may need to be formalized in the healthcare curriculum.

The outpatients department (OPD) is the hospital's shop window and often the patient's first hospital service experience. Getting OPD services right, therefore, is important. Compared to inpatient satisfaction studies, OPD reviews have probably fallen behind and certainly a less popular IJHCQA topic probably because outpatient contact is more transient than an inpatient stay and outpatients may be unwilling to hang around for an interview. Obtaining new empirical data regarding OPD services, therefore, is always welcome. Ehsan Zarei in this issue contributes to the field. Data from the author's Middle Eastern study is exposed to higher level statistical analysis. Eight OPD service quality factors were located, which largely comply with Parasuraman's tangibles. QA managers know that the tangibles (by their definition) are visible and often easily amenable to improvement; e.g., decor and seating. It is the intangibles; e.g., improving communication between staff and patients that are more challenging.

It is not hard to understand why patient safety culture takes centre stage in any country's health service quality improvement activities because the savings potential, improved outcomes and patients' quality of life, and reduced stress for healthcare staff make safety a key issue. The literature defining and describing patient safety and safety culture is getting established. How managers and clinicians perceive these definitions and safety as a whole, on the other hand, is less well understood, which Lee et al. correct in this issue. Their approach is unique; i.e., they use a safety item importance-performance matrix to highlight which safety structure and process issues are high and low value/priority. Readers may be surprised about which safety issues fall into the high performance and importance quadrants.

The extra cost attached to private healthcare means that this treatment pathway is beyond most patients' reach. Apart from shorter waiting time for tests, diagnosis, treatment and care; what else do private patients get for their money and do individual private healthcare services vary? Can best practice be emulated in public health services? Muhammad Sabbir Rahman and Aahad M. Osmangani explore Bangladeshi private patients' expectation and satisfaction – the first in their country, they believe. The constructs (closely related to SERVQUAL and SERVPERFORM) that emerge from their high-level statistical analyses probably will not surprise readers; nevertheless, if the emerging dimensions' positive features can be integrated into service provider's marketing techniques then rewards should be reaped. If state healthcare providers can emulate private healthcare's best practice then the Rahman study has wider value.

Reducing healthcare costs while improving service quality heads many country's healthcare agenda. Lean Six Sigma, as Susan Knapp explains in this issue, can make significant inroads into both. However, if “culture eats strategy for breakfast” then implementing Lean without recognizing and addressing an organization's culture, which can block or enhance Lean implementation, could be a fatal error. But what cultural issues need addressing? Professor Knapp uses an interesting technique to relate cultural types to Lean implementation. Her study generates valuable insights that should help to get managers and practitioners on board the efficiency and effectiveness train. In another Lean related paper, Maria Crema and Chiara Verbano analyse the connections between Lean and clinical risk management. Surprisingly, they found little direct connection between the two in their literature review possibly because Lean is viewed as an approach to improving efficiency rather than effectiveness. The authors failed to confirm a synergy between Lean and clinical risk management from the current evidence; clearly an area ripe for research. Reading a third Lean focused article, I am surprised that Lean methods have not been tied more closely to health and social care workforce planning and development (WP&D), since there are mutual benefits in bouncing one off the other. Numeruous articles published in IJHCQA and other QA oriented journals more often relate Lean to efficiency (doing things right) but less so (as raised above) to effectiveness (doing the right things). A wrong is righted in this issue; i.e., Scott Wilson and colleagues explore Lean's value to redesigning Scotland's children and adolescent mental health services (CAMHS); a speciality in demand and with a small staff pool from which to draw the workforce owing the highly specialised knowledge and skills required. The authors explore how the Choice and Partnership Approach (CAPA) demand and capacity Lean-based model was implemented and its impact on service efficiency and effectiveness in which staff capacity features strongly. The authors process and output benchmarks are especially illuminating. Outcomes clearly show benefits to child and young mental health service users.

Medico-legal and especially litigation issues consume huge resources in westernized healthcare. In this regard at least, prevention is better than cure, especially from the patient's perspective. From the clinicians and managers viewpoint; issues (errors and complaints in this case) need to be understood before prevention and reparation can be achieved. However, life is not that simple; i.e., it is reasonable to assume that there should be connection patient complaint, clinical error and medico-legal claim data (usually held in separate databases), but Paul Goldsmith and colleagues in this issue provide a disheartening account, which the authors claim, rightly, prevents quality improvement activities.

Early warning scores (EWS), which detect a deteriorating patient's condition and often trigger escalation in the patient's care, often compulsory is many health services, are proliferating. But as Gary B. Smith and colleagues explain in this issue, proliferation may be causing problems for patients and staff. If EWSs are not fullfilling their purpose – a means to end – then empirical reviews are needed. Professor Smith and colleagues, probably the UK's EWS leading experts, take stock by reviewing a EWS article recently published in IJHCQA. Practitioners will find the author's simple but effective debate about detection and escalation structures and processes highly educational and their recommendation that EWS guidance is reviewed and the medical and nursing curriculae updated sound.

Keith Hurst