Bottom-up quality improvement theory and practice

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Article publication date: 4 October 2011


Hurst, K. (2011), "Bottom-up quality improvement theory and practice", International Journal of Health Care Quality Assurance, Vol. 24 No. 8.



Emerald Group Publishing Limited

Copyright © 2011, Emerald Group Publishing Limited

Bottom-up quality improvement theory and practice

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 24, Issue 8

Waiting lists develop when service demand and supply are mismatched and are said to be a necessary evil; a rationing mechanism that controls scarce resources and discourages frivolous referrals. Their impact on patients’ quality of life, however, is significant and waiting lists deserve fuller attention. They are an unusual phenomenon because they are relatively stable and their dynamics are complicated. Henrik Eriksson and colleagues in this issue, therefore, explore waiting list assumptions – notably whether the solution is to pump-in more resources and whether this solution is sustainable. The authors explore waiting list theory and practice before implementing an action research project to improve Swedish hospital outpatient performance. Three case studies carefully describe improvement strategies, which include some novel approaches. Encouragingly, the authors show that additional resources are not always needed for sustained service improvement.

Medical consultation times are short and if the patient is unforthcoming then there is risk that deterioration and potential complications can be missed. So, if we built in statistical process control (SPC) techniques to detect out-of-control events electronically into patient records then would service quality improve? Pedro Oliveira and colleagues concentrate on the fourth commonest cause of death (chronic respiratory disease) and use SPC to minimise hospital admission, treatment costs and patient disruption. They triangulate various SPC techniques to highlight each approach’s strengths and weaknesses. The methodological algorithms are clearly presented and the results, displayed as simple line graphs, easily highlight patients’ actual and potential clinical problems especially when, clinically, the out-of-control events were not evident. Their findings show there are SPC horses for courses, a valuable, important and interesting finding for our readers. Clearly, the authors’ method and findings are more ammunition in the evidence-based armoury.

The ISO 9001 standard has an intriguing place in health service accreditation. Designed for industry and commerce, the standard helps service managers detect and correct procedural flaws – a robust TQM approach. Owing to its pedigree, ISO 9001 has a chequered history in healthcare. Gad Vitner and colleagues, interestingly, apply the standard to perhaps the most specialised and challenging environment – a neonatal intensive care unit (NICU). Their article is valuable to our readers for several reasons. They neatly summarise articles (a surprisingly broad range) describing where ISO 9000 has been applied to healthcare – valuable alone for lessons learned. They carefully describe implementation structures, processes, outputs and outcomes in the unit – paying equal attention to all Donabedian elements. Although not a case-controlled design (therefore, confounding variables were not controlled), the differences before and after ISO 9000 were implemented are staggering – notably parent satisfaction scores. Anyone reading the article might feel NICU ISO 9000 is a winning strategy and one would be crazy not to attain accreditation via ISO.

Accreditation is a laudable aim. But its top-down approach often puts-off coal-face workers. So what better approach than to ask healthcare managers and practitioners to help design accreditation guidelines (Skills Manuals)? Víctor Reyes-Alcázar and colleagues describe Andalusia’s detailed evaluation approach. The authors underline that most user-involvement articles focus on patient- rather than staff-users. Consequently, their qualitative, interview-based study generates remarkable insights into accreditation enablers and barriers. We are also briefly reminded about frameworks (from the literature) in which to think and act about user involvement. It seems that stakeholder selection and involvement are the main drivers while excessive (design committee) workloads discourage participants.

Patient satisfaction studies, always a popular IJHCQA author and reader topic, are enjoying resurgence as they head to more sophisticated levels such as connecting patient satisfaction with customer loyalty. In this issue, Mosad Zineldin and colleagues compare patient satisfaction results after using the same research instrument in three developing countries, where patient satisfaction data are an integral QA programme component. They used the pre-tested and well-tried 5Qs patient satisfaction questionnaire in Kazakhstan, Egypt and Jordan. Kazakhstan, the most recent country to be studied, is a rapidly expanding, resource rich nation although its health service remains heavily influenced by the USSR’s state-owned approach. Similarities and differences between the three different country’s patient views emerge, notably their focus on hospital infrastructure. Consequently, the authors are able to recommend significant policy and practice actions.

Despite its value and importance, articles about the European Foundation for Quality Management (EFQM) dried-up two years ago (at least in the IJHCQA), so it is refreshing to read a submission about a recent EFQM project’s nature and value. Readers will remember that EFQM is a self-assessment and improvement technique. Moreover, it is interesting to see how EFQM is applied to dentistry. Fatmi Zafar and colleagues remind us about broader QA definitions before using EFQM’s eight principles to evaluate a relatively new and expanding Indian dentistry service – one service with unusual characteristics (combining private healthcare and higher education). The authors converted EFQM principles into an interview schedule before interviewing university students and staff. Their qualitative approach generated interesting insights – notably that five from eight EFQM pillars were perceived unsatisfactory. Consequently, the authors are able to make several recommendations to improve dental policy and practice.

Articles describing socio-economic studies are always welcome – especially those empowering disadvantaged patients. Patience Abor and colleagues, in this issue, write an unusual, interesting and vitally important article about Sub-Saharan African (SSA) women’s access to maternity services. I had not thought seriously that service uptake and service quality is a two-way process; i.e. one drives the other and vice-versa. In the SSA women’s case, there are other drivers, so maternity policy and practice studies are vital. The authors define key data and remind us about developed and developing country maternity statistics (SSA’s pregnancy-related mortality figures, which are especially alarming). Another useful component in their article is health service funding options open to service users and how these are changing during austere times. Many will have read about micro-financing (start-up grants) for families in deprived areas. Perhaps what may be new to readers is the impact special monetary schemes have on mother’s empowerment, healthcare service uptake, family health and their knock-on effects. From their systemic review, the authors describe three channels (individually or combined) to help women and their families, which need piloting and testing so that maternity healthcare policy and practice, hopefully, are adjusted to improve service uptake and quality.

Keith Hurst