Patient-based efficiency and effectiveness strategies

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Article publication date: 19 July 2011



Hurst, K. (2011), "Patient-based efficiency and effectiveness strategies", International Journal of Health Care Quality Assurance, Vol. 24 No. 6.



Emerald Group Publishing Limited

Copyright © 2011, Emerald Group Publishing Limited

Patient-based efficiency and effectiveness strategies

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 24, Issue 6

Amira ep Koubaa Eleuch in this issue follows-up an article published in IJHCQA Vol. 21 No. 7 describing how SERVQUAL was used to measure patient expectation and satisfaction. The author stresses that different stakeholders in the healthcare sector (patients, providers, practitioners and insurance company staff) should cooperate to assure patient safety and satisfaction. At the same time, healthcare providers can compete with the other to improve patient loyalty and maximise profit using their limited resources in a highly competitive environment. The study highlights the necessity to evolve and enhance technical quality in Japanese healthcare settings. The country’s culture and healthcare characteristics are used to explain and interpret results. The main three factors behind patient satisfaction in Japan were “staff behaviour when delivering the service”, “technical quality” and “physical appearance”. These results indicate that patients in different cultures, such as Japan or Kazakhstan, evaluate healthcare services differently, which may need different responses from managers and practitioners.

Taboo subjects, it seems, can seriously influence service quality. It’s more than simply denial about diagnoses and prognoses or healthcare professionals’ reluctance to broach prognosis and survival issues with patients. Enablers and hinderers to cancer patients discussing life quality could make or break a patient’s coping ability, however. Consequently, Jakobsson and Holmberg take a close, qualitative look at how Swedish prostate cancer patients make sense of their situation – notably what hampers and hinders communication between patients and staff. Making sense of situations in which patients find themselves is a complex psychosocial process, so the authors’ literature review helps readers understand complex phenomena. Trust and confidence is important for patients to make sense of their lives and nurses as the primary carers, therefore, have a special role. Dialogue between patients and nurses is important, which is the authors’ focus, using interviews with sufferers. Findings are interesting and helpful; for example, some patients expect nurses to intuit their problems rather than opening-up to staff, which could be problematic when barriers such as staff workload, age and gender differences between nurses and patients may be barriers. However, competent staff could easily sense the need for patients to discuss then facilitate sensitive discussions. Also, are we giving patients the right information, using the most appropriate media? Interestingly, some patients complained about being overloaded with less-relevant information and being starved about the most important guidance and facts. Clearly, communication and cancer patients’ continuing care go hand-in-hand – a subject deserving more attention.

Patient consultations with general practitioners are probably the most frequently occurring, substantive health service activity. These consultations also have gatekeeper/service access and shop window functions. Consequently, getting appointment systems to run efficiently and effectively is an important service-quality enabler. Sliwa and O’Kane in this issue take appointment systems apart. They aim not only to provide new insights into appointment system impact on service quality but also developing a Rolls-Royce measuring system. Their quantitative (process control appointment time and wait analyses) and qualitative (stakeholder interviews) contribute to both aims. The authors found remarkable variations in appointment waiting times (ranging from one to eight days) and consultation punctuality (running five to 21 minutes late) between general practices. These differences were underlined independently during interviews with stakeholders so awareness is high and frustrations likely. Encouraging general practice staff, therefore, to measure and improve appointment systems seems worthwhile.

We are pleased to publish an unusual and important study in this volume. Most of us will have dealt with overseas call centres at some point (e.g. banking services). Offshoring services are cheaper for home country organisation staff because overseas staff are cheaper to employ than local staff. It’s hardly surprising, therefore, that outsourcing is expanding to include health services. The outsourcing range is extensive – from relatively straight-forward transcription services to complex such as remote surgery. Should we be concerned that costs override service-quality issues? Should patients be concerned that their X-rays and scans are being read accurately, or that privacy and confidentiality are at risk in outsourced service providers? Kshetri address these questions in this issue. Outsourcing (off-shoring) is defined, actual and potential subcontracted health services to other countries are described and pros and cons are explored. Other than service-quality and confidentiality issues, there are worries surrounding usurping jobs in the home country even though services known to have recruitment and retention issues in the home country are selected for outsourcing. Legislators seem to go out of their way to discourage outsourcing opportunities. However, there is evidence that outsourced service providers in India and The Philippines deliver better-quality services. It seems therefore, that we have moved on from initial fears about developing these services to concentrating on protocols to encourage and facilitate low- and high-value outsourced services.

American emergency departments (ED) are the first contact for most patients with life threatening illness/injury. Emergency department services are valuable and deserve investment since staff save and improve quality of life for thousands of attendees. However, US ED staff deal with 115 million (and rising) attendances each year. In total, 47 million US citizens (one in seven) have no health insurance, which accounts for 20 per cent of these visits. Of ED visits, 64 per cent are low to medium severity, among mostly self-paying or uninsured attendees – non-urgent ED attendances are growing substantially. Americans have a legal right to emergency care but the US population is growing and ED attendances are soaring – affordability and waiting times are increasingly important, therefore. These concerns, along with service abuse (inappropriate attendances), occur in ED services that are shrinking owing to financial problems because reimbursement is limited. Moreover, ED staff recruitment and retention are problems owing to the stressful nature of ED work, causing some departments to close. Consequently, Harrison and Ferguson in this issue take a close look at US ED dynamics and their policy and practice implications. For example, the knock-on effects when thinly spread EDs are full and ambulances are diverted to EDs elsewhere in the locality are severe. The authors’ analyses generate remarkable insights into macro and micro ED policy and practice – lessons from which ED service managers and practitioners in all countries could benefit.

Several years back I evaluated patient-focused care’s (PFC) effect on NHS quality. Results were mixed – in sort, PFC turned out to be a flash in the pan. Patient-focused care was derived from business process re-engineering (BPR), the subject of an extensive study and subsequent article published in this IJHCQA issue. Business process re-engineering survived while PFC fell off the agenda. Clues appear in the article by Said Abdel Hakim Rateb et al. and her Egyptian colleagues. They successfully applied BPR to Egypt’s pre-employment health screening services (two million clients a year), with encouraging results. As far as the authors could tell, this was the first time BPR had been used in Egypt’s health service. They remind us about BPR’s nuts and bolts before randomly selecting six pre-employment health screening services. Donabedian’s triad is their theoretical framework in which process flow studies underline service bottlenecks, using multiple internal and external customer-focused methods to collect data before and after BPR was applied. Their customer-friendly approach led to significant efficiency and effectiveness gains; notably reduced costs, increased internal and external customer satisfaction and better revenues. Comprehensive, all-round service improvements materialised, so applying BPR to healthcare clearly works as this study shows. Lessons can be learned not only within Egypt but also beyond, not least some fairly brutal service changes may have to be made in stagnating organisations unlikely to survive.

Keith Hurst

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