5/7/2017

Quality in Health Care

Year 5 Community Health Clerkship
Public Health

Updated May 2017

The science and art of preventing

disease, prolonging life and promoting
health through the organized efforts of society

What Public Health involves

• Populations vs individual

• Public health physicians do not treat individual patients

• Contact tracing e.g. meningitis, tuberculosis

• Epidemics e.g. dengue

• Vaccination programmes….coverage, adverse effects

• Screening programmes….coverage...quality assurance

• Health service planning and evaluation…

• Emergency planning ….terrorism, natural disaster, pandemic…

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No bed space so woman gives birth in toilet…..

Hospital medical director confirmed there

was no bed space…..

But, he could not give an explanation for

the behaviour of the nurses

The patient claimed nurses ignored her

when she told them she was in labour

……..after Mother C delivered her baby at 12.24 pm,

her vital signs (blood pressure, heart rate) were not
monitored until 2.15 pm while she lay on a bed in
the maternity ward.

“A doctor saw the patient at 4 pm and wrote ‘vital

signs not done,”…….

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Objectives
At the end of the session you should be able to:

• Explain what is meant by quality in health care

• List and differentiate Donabedian’s parameters

• List and differentiate Maxwell’s 6 quality criteria

• Describe the audit cycle

• What do you think constitutes a quality

(health) service?

Car service

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What is quality health care?

The extent to which health services provided for
individuals and populations increase the likelihood of
desired health outcomes and are consistent with
current professional knowledge..

The care should be provided in a technically and

culturally competent manner with good
communication and shared decision making and
based on the strongest clinical evidence

Differing Perspectives of Quality

What do you think is priority for the various

groups:

• Consumer/patient - ?

• Clinician - ?

• Commissioners/funders - ?

Differing Perspectives of Quality

• Consumer/patient – responsive to perceived
care needs; level of concern, communication,
courtesy, symptom relief, level of functional
improvement

• Clinician - degree to which care meets

technical state of the art; freedom to act in
interest of patient, accountable to
professional standards

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• Commissioners/funders - efficient use of

funds available for health care, accountabilitily
to politically set objectives, targets and goals

Avedis Donabedian
• The founder of the study of quality in health
care

• Outlined why it is important to study health

care quality looking at:
structure, process and outcome parameters.

Structure
• Structural parameters include resources - both
human and material

• Staff employed for a specific purpose must be able to

carry out that task effectively i.e. they must be
suitably qualified

• The necessary building, equipment and supplies to

carry out required functions must be present eg
hospital, beds, laboratory…

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Process
• Pathways of care...referral

Can measure:

• Patient experience in terms of waiting times

• Patient satisfaction may be measured
• Time for receipt of results of investigations

Outcomes
Outcomes may refer to:
-death
-survival with morbidity
-survival

Example 1
• Hospital A – 100 appendectomies; 5 deaths

• Hospital B – 100 appendectomies; 1 death

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Hospital A
Busy hospital…overcrowding
Understaffed
Teaching hospital …junior doctors
Referral centre
More elderly patients

Hospital B
Quiet, suburban hospital
Younger, middle class patients
Senior surgeon

Robert Maxwell
1984

UK

Opening times
Accessibility

Acceptability
Efficiency
Patient satisfaction
Communication Quality Health
Waiting times, cost
Care

Equitable Relevant
Effectiveness

Staff; equipment;
Evidence based medicine

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Maxwell’s dimensions of quality

• Equitable - fairness, equal access for equal need

• Accessible - can services be reached?
• Effective - does what it is supposed to do
• Efficient - output /input = maximum ($, time)
• Acceptable - humane, considerate
• Relevant - appropriate to needs of the
community

‘The enjoyment of the highest attainable

standard of health is one of the fundamental
rights of every human being without
distinction of race, religion, political belief,
economic or social condition’
[Constitution of WHO – World Health Organization]

Example 2
• Pregnant patient comes into hospital bleeding
PV and dies within 2 hours

• What factors would you consider when

reviewing this death?

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• Patient called ambulance and waited 2 hours

• House officer on duty - 1st night on call as House
officer
• Did what he could but needed to call Registrar (who
is off site)
• Cross matched patient
• Delay in sample getting to laboratory as one porter
on duty
• No blood available for the patient
• By the time the registrar arrives, the patient had died

Maxwell’s Quality Dimensions

• Accessibility means the patient is able to
access the service in terms of waiting times,
and not excluded because of location of
services, ability to pay, for example.

• Acceptability means the service is acceptable

to patients i.e. not uncomfortable, culturally
sensitive, humane and considerate, privacy
and confidentiality safeguarded

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• Effectiveness refers to the service doing what

it is supposed to do and is evidence based
with appropriately qualified staff, does the
intervention have the desired effect

• Efficient refers to obtaining maximum output

for minimal input, how does unit cost
compare with unit cost elsewhere for the
same treatment/service

• Equity ensures equal access for equal need

considering all groups regardless of language,
disability; are patients/groups of patients
being fairly treated relative to others?

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Ethical principles
• Beneficence – helping the patient

• Non maleficence – not harming the patient

• Autonomy – the rights of patients; respect for the

patients autonomous decisions

• Justice – equity

Justice
• Distinguish equity and inequality

• Equity = fairness and justice; ethical dimension

• Equity is about avoiding unfairness in opportunity

and choice

• Equality is about comparing level of health between

populations

Justice
• Women live longer than men – unequal but not inequitable

• Cigarette smokers have a higher incidence of lung cancer than

non smokers – inequality but ? inequitable because created
by choice

• Lifestyle and behaviour if not freely chosen – unfair e.g.

Bhopal, Savar

• Inadequate access to health care – inequitable if cause

avoidable e.g. lack of access to information about services due
to learning or language problems or information not being
available

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Bhopal Chemical Incident 1984

•Leak of methyl
isocyanate gas
•>3800 deaths
•Significant morbidity
•Premature death
•Compromise of safety
standards

Savar Bangladesh 2013

The scale of the April 24 2013 disaster has
prompted a worldwide outcry at poor safety
and pay in many factories making clothes for
Western brands, with Pope Francis on
Wednesday likening the conditions of workers
who died to "slave labor".
Cracks appeared in Rana Plaza the day
before its collapse. Both the police and the
Bangladesh Garment Manufacturers and
Exporters Association (BGMEA), a powerful
lobby, told the owner his building was
unsafe but he ignored them and the
factories stayed open. Workers said they
had been pressed to show up because
orders were overdue.

There were about 3,000 people

inside the complex, which was built
on swampy land, when it collapsed.
About 2,500 people have been
rescued, many injured, but many
remain unaccounted for.

Inequality
• Social responsibility
• Can you attribute inequalities in health to
individual responsibility?

• A smoker --- lung cancer ….is it his fault?

• A skier -- breaks his leg….is it his fault?

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• Relevance refers to services being tailored to

the needs of the local population, is the
overall pattern of services the best that could
be achieved taking account of needs and
wants of the population as a whole?

How to measure quality?

• To assess and improve quality, need to
measure it

• Quality indicator – statement about a specific

healthcare process that should be delivered
under specific clinical circumstances

Setting Quality standards

Should the benchmark be the average or the best
possible?
-Excellent standards
-Minimally acceptable
-Achievable
In practice to be useful standards:
-should be attainable
-individuals must be clear on how to achieve them

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RHAs
• QISC
• QIRMC

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