Strengthening healthcare quality through identification of risk, improving quality standards and an outlier considering the integration between environmental status and human health

Citation

MacVane Phipps, F.E. (2021), "Strengthening healthcare quality through identification of risk, improving quality standards and an outlier considering the integration between environmental status and human health", International Journal of Health Governance, Vol. 26 No. 3, pp. 323-329. https://doi.org/10.1108/IJHG-09-2021-139

Introduction

Even in editions of IJHG that are not themed, some commonality can usually be found. It was somewhat tricky in this issue as there was a clear outlier in the articles accepted for publication. While a common thread could be developed around identification of risk and improving quality in healthcare, the outlier brought in environmental, animal welfare and political perspectives. However, an unexpected paper in any collection can act as a “wake-up call” forcing us to re-think assumptions and establish new pathways of connectivity. I would hope that this issue's outlier encourages other authors to be brave and to tackle subjects, which perhaps do not have a direct path back to our original remit of clinical governance (CG). Encouragement towards thinking more deeply and widely can only be a good thing for clinicians and academics to avoid becoming trapped in silos of our own creation.

Clinical governance and hospital performance in Ghana

This review is based on the following study: Azilaku JC, Abor PA, Abuosi AA, Anaba EA and Titiati A (2021), Relationship between clinical governance and hospital performance: a cross-sectional study of psychiatric hospitals in Ghana IJHG 26 (3) ahead-of-print: https://doi.org/10.1108/IJHG-04-2020-0042

The effectiveness of CG is based on the integration of clinical and managerial approaches to improving the quality of healthcare provision. The concept of CG was initially presented as part of a National Health Service (NHS) White Paper in 1998 (Wilson, 1998). Over the past 20+ years, it has been widely adopted in the UK in order to improve quality, efficiency and public involvement in healthcare provision. However, CG has not been widely adopted in sub-Saharan Africa. This paper focuses on Ghana where there are widespread issues concerning both the quality of healthcare and the poor service conditions for healthcare workers.

The authors examine the implementation of CG in two psychiatric hospitals in Ghana through the use of a structured survey tool. A questionnaire was administered to 300 members of staff in the two hospitals. Respondents included doctors, physician assistants, nurses, occupational therapists, psychologists, biomedical scientists and social workers. A total of 230 questionnaires were completed indicating a response rate of 77%.

Analysis of data found a direct correlation between key CG components and hospital performance. In particular, the implementation of risk management strategies, clinical audit and quality assurance measures, and ongoing staff education and training were related to better performance. Measurable outcomes included use of appropriate procedures, reduced patient waiting times and increased patient satisfaction. While this study demonstrated some movement toward improving care through the adoption of CG in Ghana, it also revealed that care and conditions in the psychiatric hospitals reviewed remained sub-optimal in many respects.

Identifying frail elders in the community

This review is based on the following study: Van der Elst M, Schoenmakers B, Dierckx E, De Roeck, E, van der Vorst A, Lambotte D, De Lepeleire J and De Donder L (2021), Towards a more effective strategy to detect community-dwelling frail older adults: validation of risk factors. IJHG 26 (3) ahead-of-print: https://doi.org/10.1108/IJHG-11-2020-0131.

The world population of older adults is rising, and this raises questions about the best methods of meeting their complex needs. Caring for older adults in the community has both economic and social benefits. Institutionalization is costly, and many older adults express a desire to remain in their own homes as they age and frailty increases.

A major problem with providing care in the community is in identifying which older adults require care. Age alone is not a good indicator of need; a targeted approach based on frailty might be more effective.

The Belgian ageing studies’ data identify four different domains of frailty as well as risk factors for entering these domains. The four domains are physical, social, environmental and psychological. The socioeconomic risk factors are identified as net household income and education. Socio-demographic risk factors include age, country of birth, relocation within the past ten years and marital status. A recent study headed by Natasha Wood of University College, London (UCL) measured two determinants of physical strength in older people and found that married people were less frail than their unmarried counterparts (Wood et al., 2019).

Frailty is seen as a dynamic state, which can, to some extent, be reversed, especially if identified early enough. The goal of the research by Van der Elst et al. (2021) was to validate previously identified risk factors for frailty. This study shows that older individuals who are on the scale from mildly to highly frail are most likely to be positive for at least three risk factors. By identifying which older people have three or more risk factors would, therefore, be an effective screening tool to target individuals for early intervention before frailty becomes irreversible. Risk factors are not fixed entities but need to be reconsidered population demographics change. For instance, as divorce or moving in retirement become more common, the impact of these factors may alter.

Organizational factors and clinical quality trade-offs

This review is based on the following study: Glette MK and Wiig S (2021), The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature. IJHG 26 (3) ahead-of-print: https://doi.org/10.1108/IJHG-12-2020-0134.

Glette and Wiig (2021) present a thematic synthesis of the literature into balancing organizational demands and healthcare quality.

How can healthcare providers continue to meet increasing demands and costs with decreasing resources and continue to deliver a service, which meets quality indicators? Healthcare personnel are increasingly employing the efficiency–thoroughness trade-off principle (ETTO principle), which involves a highly skilled balancing act if intended outcomes are to be achieved and errors avoided or mitigated (Hollnagel, 2009). The Institute of Medicine (IOM) defines quality healthcare as services for individuals or populations that increase the likelihood that desired health outcomes are achieved and which are congruent with current medical knowledge (Allen-Duck et al., 2017). There is a dearth of research into the impact of this balancing act on the quality of care received in any particular setting or population.

Glette and Wiig (2021) sought to identify the role of organizational factors in influencing ETTOs. Standard literature searching and review protocols were used in decisions regarding identification and inclusion of appropriate research articles. Papers were evaluated using the previously validated critical appraisal skill programme tool (CASP) and the mixed methods appraisal tool (MMAT) (Long et al., 2020; Hong et al., 2018).

Following data extraction, data were organized into initial broad categories, and later these were refined to create more precise sub-categories. Data analysis identified four main categories of how healthcare workers make ETTOs and how these are influenced by organizational factors. Key organizational factors included staff shortages, high workloads and time limitations. There were several examples in drug administration, including leaving drugs with relatives to administer, administration of drugs by a different nurse to the one who had checked the drugs and allowing health clinic receptionists prescription-writing responsibilities for some medications.

In some cases, organizational attempts to create greater efficiency were subverted by healthcare staff, who felt these compromised safety. One example was a hospital directive that ambulance staff hand over care of patients at just one point to a nurse with a dedicated role in admissions. Ambulance crews persisted in providing a second unofficial handover to nurses taking on the care of patients because both the nurses and the ambulance staff were concerned that important information could be missed through the use of the single stage handover. Another example concerned was doctors who ignored working time directives, designed to prevent burn-out, in order to complete tasks. While the doctors felt that they were protecting patients by completing a care cycle, research indicates that care delivered by fatigued medical staff is less safe (Hall et al., 2016).

The World Health Organization (WHO) has recognized that greater efficiency and better use of existing resources are required to meet their goal of gaining universal healthcare coverage. However, increased efficiency may come at the cost of a reduction in quality. This causes conflicts between organizational goals and nursing goals: the first focused on efficiency and the latter, on quality. Professional ethics may also favour quality over efficiency and may lead doctors and nurses to refuse or try to work around efficiency measures, which they see as potential violations of their professional codes of conduct. This may be particularly difficult for nurses whose role in clinical decision-making is often somewhat ambiguous (Dowie, 2017).

This study confirms experiential knowledge of staff providing front line care around the globe. While health professionals deal with the implications of the ETTO principle on a daily basis, research evidence is a necessary tool in demonstrating how this can be done most effectively.

Challenges around the participation of NGOs in Iran's healthcare provision

This review is based on the following study: Rajabi M, Ebrahimi P, Aryankhesal A (2021), Participation of non-governmental organization in Iran's health system: Challenges and suggestions for improvement. IJHG 26 (3) ahead-of-print: https://doi.org/10.1108/IJHG-02-2021-0021

Rajabi et al. report on the challenges of integrating non-government organizations (NGOs) into the state healthcare system in Iran. An explorative qualitative methodology was used to elicit the opinions and insights of experts and managers working for the Ministry of Health and in medical science universities and of CEOs of NGOs in the health sector.

Analysis of data carried out within a validated corporate governance framework revealed both internal and external challenges. Internal challenges had to do with the nature and function of the NGOs, while external challenges were related to society and government.

The latter included a lack of trust of NGOs on the part of the government, the absence of clear laws governing the function of NGOs and the multiplicity of government agencies dealing with NGOs, all of which have different policies concerning licensing the practice of NGOs.

Internal issues included the corruption of the NGO's advocacy role toward self-interest for economic or political purposes, the inclusion of government ministers on NGO boards, thus blurring boundaries, and problems attracting sufficient funding from sponsors and philanthropists.

Suggestions for improving coordination between government health services and NGOs included adopting specific laws concerning the purpose and function of NGOs, requiring NGOs to engage in strategic planning by formulating measurable goals every 3–5 years and by establishing support mechanisms for NGOs through providing guidance and budgetary help where required.

Reforming psychiatric care: a historical examination of the abusive culture of the 1960s

This review is based on the following study: Powell M and Hilton C. (2021), How the Sans Everything and Ely inquiries put reform of psychiatric hospitals onto the United Kingdom government agenda. IJHG 26 (3) ahead-of-print: https://doi.org/10.1108/IJHG-03-2021-0024

In the early years of the NHS, there was a growing recognition that conditions in mental hospitals, and what were then known as mental deficiency hospitals in the UK, were unacceptable. Understaffing and overcrowding combined with a general lack of understanding and stigma about mental health and learning disabilities lead to mental hospitals being referred to as “disgraceful” and as “slums”.

This research uses multi-streams analysis (MSA) to examine two enquiries into mental health provision in the 1960s, seeking to explain the mechanism for changing attitudes, policy and practice. MSA examines health through the problem stream (what is the issue), the political stream (institutional and cultural context and their impact on care given) and the policy stream (analysis of the problem and expert proposal on how to solve the problem). The different streams remain fairly independent of each other until a “policy window” opens. The simplest way to explain this is to say that an enquiry opens a policy window, which then requires the multiple streams to be considered together in order to resolve the problem.

By applying MSA to the problems in psychiatric and mental handicap facilities in the 1960s, it is clear that an awareness of the problem of overcrowding and staff shortages existed. Politically, this became a relevant issue as investigative journalism raised public interest in the situation. Ongoing public interest led eventually to policy changes to improve psychiatric and mental handicap care.

Improving health boards' governance of quality and risk

This review is based on the following study: Avery MJ, Cripps AW, Rogers GD (2021), Health boards' governance of quality and risk: quality improvement agenda for the board. IJHG 26(3) ahead-of-print: https://doi.org/10.1108/IJHG-01-2021-0006

Public and private health boards in Australia are responsible for managing quality standards and reducing risk. Health institutions in both the public and private sector operate within a comprehensive legal and ethical framework (Biggs, 2013). In this study, the research team interviewed health board non-executive directors to explore strategies employed to manage risk and improve the quality of patient care. Interviews were taped and transcribed verbatim, and then the data were analysed to identify systems and actions that add value or make a contribution to healthcare governance in terms of increasing quality and avoiding risk.

Factors attributed to the effective functioning of hospital boards included appointment to the board based on functional skill-sets, ongoing training and education and regular reflective self-assessment. A key problem identified was the dearth of board members with skills related to data mining and information generation. As data become ever more complex, specialist skills are required in order to interpret and operationalize this flood of information.

The role of health boards continues to be vitally important in healthcare governance of increasingly complex health services. To deal with this, boards need to develop very clear agendas around safety and quality and ensure their membership includes expertise in all required fields.

Reducing meat consumption by innovations in taxation

This review is based on the following study: Simmonds P. and Vallgårda S (2021), “It's not as simple as something like sugar”: Values and conflicts in the UK meat tax debate. IJHG 26 (3) ahead-of print: https://doi.org/10.1108/IJHG-03-2021-0026

This is an interesting article focusing on the benefits and detriments of using taxation to reduce meat consumption. The issues surrounding meat consumption are as much about environmental concerns and animal welfare as they are about human health. However, in the long-term, climate change is the biggest threat to human health in the history of the planet; therefore, both the direct health benefits of reducing red meat consumption and the indirect environmental benefits of reduced factory farming can be viewed as important health issues.

A meat tax would be what is known as a Pigouvian tax named after early 20th century economist, Arthur Pigou. It aims to levy tax on the real cost of goods or services, including cost to those not directly involved in any one transaction (Kallbekken, 2013). For instance, a tax on meat would aim to reduce meat consumption, and while the health benefits of eating less meat would only affect the shopper making choices about meat purchases, the environmental benefits would affect the population as a whole.

The authors collected data through an initial literature search of news articles containing the phrase “meat tax”. Articles where this was only mentioned in passing were excluded, as the aim of the literature search was to explore the arguments for and against a meat tax. In total, 25 articles were used as data sources; these were categorized using Baumgartner's description of political conflict levels (Baumgartner and Jones, 2009). These articles ask questions about the nature of the problem, the best solution to the problem and the most effective methods of implementing the solution.

The second phase of data collection involved interviews with appropriate stakeholders from academic, industry, civil society and think tank domains. While the authors originally planned to interview politicians, it was not possible as the UK Parliament was not in session due to the 2019 election campaign. However, the authors note that a meat tax is only mentioned in the manifesto of one political party, the Green party; therefore, politicians from other parties may have been unwilling to discuss proposals for a meat tax in the absence of a clear party line.

Interviews were recorded and transcribed (n = 9) while a single interview was conducted through the medium of email. Initial analysis using NVivo 12 Plus software used a deductive approach to identify preliminary categories. Inductive coding was then used to develop a richer interpretation of arguments, such as those pertaining to animal welfare and animal rights. One author kept a reflective journal to record emerging interpretations and concepts and then discussed these with the second author.

Findings included five major themes: climate change and environment, human health, effects on animals, fairness and acceptability of government intervention. However, no clear solution emerged as both literature and interview data were polarized along political lines with an ongoing argument as to whether levels of meat consumption in the UK were actually a problem.

Conclusion

The seven articles in this issue of IJHG provide interesting food for reflection about aspects of health governance in today's rapidly changing global environment. Six of these articles encourage consideration of issues relating to managing risk and improving quality. Avery et al. (2021) remind us that to be effective monitors and planners in healthcare facilities, it is essential that board members have the management skills required to move healthcare through the 21st century with all the existing and potential future problems of this period in time. Azilaku et al. (2021) describe the first steps of entering into a clinical governance mindset in Ghanian hospitals. This indicates progress with the potential to reduce risk and improve quality but requires doctors, managers and other health workers to sign up to a clear commitment to create an ethical, equitable and modern health service. Rajabi et al. (2021) report on the problems of integrating state healthcare provision with healthcare provided by NGOs in Iran. Successful integration could go a long way to reduce risk and improve the quality of care in both sectors. The authors have outlined some solutions. Powel (2021) takes a historical perspective, illuminating problems in a new health service lauded by the UK government as “the best in the world”. Clearly for psychiatric and mental disability patients in the 1960s, it was not the best, and this paper details failures in the system while highlighting elements leading to change. Glett and Wigg (2021) introduce the concept of the ETTO principle. The ETTO describes what healthcare professionals do on a daily basis to attempt to minimize risk and increase care quality while grappling with issues such as staff shortages and increasing healthcare demands. Van der Elst et al. (2021) focus on a problem which affects us all, as we all face both our own eventual frailty and perhaps more imminently, the provision of care for older relatives. They propose developing a tool using the four domains of frailty and the demographic risk factors to identify which of the elderly population are most likely to suffer from frailty and thus be most likely to require community care. The outlier, as previously mentioned, is the article by Simmonds and Valgarda (2021) on the proposed meat tax in the UK. Combining a concern for human health and animal welfare with political expediency and environmental protection, this article is not easily slotted into a theme of reducing risk and improving quality. However, to ignore the issues is to close our eyes to problems that will increasingly affect global health. Therefore, I welcome this submission as something to stimulate our brains and remind us that health is a much wider issue than providing prevention or cures in hospital or community settings.