Gourlay, R. (2004), "Quality and more quality", International Journal of Health Care Quality Assurance, Vol. 17 No. 7. https://doi.org/10.1108/ijhcqa.2004.06217gaa.001
Emerald Group Publishing Limited
Copyright © 2004, Emerald Group Publishing Limited
Quality and more quality
Looking back over the last 17 years (the length of time the Journal has been published) it is possible to track considerable progress in the management of quality in Health Care. In the UKs National Health Service, the most significant innovation was that of clinical governance and charging the Chief Executive with responsibility for all aspects of quality.
Among other initiatives this gave continuous stimulation to the development of clinical audit, risk management, and systems to protect the patient from poorly performing doctors and mistakes during treatment. It has, in other words, been a few years of considerable change and innovation in the field of quality management.
However, anyone will realise that there is still some way to go to match the practices of some commercial enterprises especially in the field of electronics. Perhaps one avenue which has not been explored quite a fully as some others is summed up in the title of Philip Crosby’s book “Quality is Free”. The thesis is that by squeezing out the costs of poor quality, it is possible to “save” enough to spend on the design and development of quality systems and concomitant staff training. Not only could such initiatives lead to financial savings, they can lead to improvements in the patients experience.
The obvious examples are those to do with process redesign. There is undoubtedly a lot still to be gained by redesigning “discharge” arrangements thereby reducing the length of patient stay. Conversely, the convoluted process for admissions lead to wasteful duplication. Some hospitals are now allowing General Practitioners to refer straight to the “table”, thereby cutting out many handovers.
On the staff training first, a careful examination of complaints on critical incidents will highlight aspects that need remedying because they consume time when things have got to be put right. For example, one of the most frequent causes of complaints are those of communications and staff attitudes. It would be interesting to find out whether the training that Disney Land staff has any merit in being replicated for health staff. Although the contexts are very different, the one similarity is maintaining a welcoming persona for some length of time.
On the “costs” front considerable stimulators to reducing “mistakes” has been provided in the UK by the establishment of the clinical negligence scheme for Trusts. Here the scheme sets out defined standards to be achieved, and as each level of standard is achieved, so the insurance premium for the Trust reduces.
This has led to, for example, much better induction schemes for staff as well as the development of guidelines and pathways. As only a few Trusts have got anywhere near the most stringent standards, it can be seen that there is still some way to go. And in Crosby’s phrase, quality is genuinely “free” as the investment made produces a cash saving in the premium to be paid. The good thing about this scheme is that the “reward” for the investment is almost immediate. It is more difficult to work up an enthusiasm for undertaking change work when the reward seems small from the effort invested. For example, reducing the amount of food wasted takes effort and co-operation but may appear to produce little benefit. Similarly with the control and stockpiling of drugs and dressings. Again the savings might appear small, but if replicated many times over many wards and departments, the “pay off” could be considerable.
The success of many of the “quality” initiatives has been achieved by stimulating and provocation from “above”. The “star” system in the UK forced attention on the “quality” state of each Trust and the CEO’s accountability forced their attention to what was being achieved managerially and clinically.
The new initiative “on the block” is that of Foundation Trusts. In this approach Trusts will have more discretion to manage their own affairs. The “sting” comes with the consequent introduction of Health Resource Groups and the practice of payment by results. This means that all Trusts have to charge the same as other Trusts for similar clinical interventions. The “charge” will be the average cost of all Trusts for the intervention. It is therefore very important for those Trusts whose costs are greater than the average, to get their costs down or otherwise they will be “running” at a loss. If any further stimulation were needed to tackle waste aad inefficiencies we would be very surprised.
In summary, clinical governance has raised the issue of clinical quality and brought some significant improvements in the patient’s experience. We now foresee that payment by results will force “managerial” quality higher on the agenda on Trust’s strive to maintain a healthy financial state – in other words not to run at a loss.