BS1036 Quality Management in the Public Sector

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BS1036 Quality Management in the Public Sector

• 11 Quality Management in Health/Public Sector

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BS1036 Quality Management in the Public Sector

• The recipients of a service are not just
• CONSUMERS of the service but also
• CITIZENS i.e. people can demand the right to
  certain services, backed up by legal authority
  and political/community pressure
• PUBLIC GOODS are provided for the whole community
  but consumption seen in a different light

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BS1036 Quality Management in the Public Sector

• Who is the CUSTOMER of local authority planning
  services ?
• the BUSINESS paying the fee for planning
  permission ?
• The ACTUAL CUSTOMERS of the business
• The FUTURE CUSTOMERS of the business
• The RESIDENTS affected by the planning
  proposal ?

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BS1036 Quality Management in the Public Sector

• Auntie Nelly needs a hip operation if Nellie
  is the CUSTOMER, then who is the PURCHASER ?
• Nellie herself (from her own resources)
• Nellies family (own resources)
• The local community (appeals for funds)
• Health insurance (BUPA,PPP)
• GP fundholder (now Primary Care Group)
• District Health Authority (in purchasing
  capacity)
• Specialist charities

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BS1036 Quality Management in the Public Sector

• Who gets the resources Child B case
• http//www.oheschools.org/ohech1pg8.html
• The treatment available to one consumer has to be
  weighed against that of other potential consumers
  when resources are limited.

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BS1036 Quality Management in the Public Sector

• Health Services share some of the more general
  characteristics of consumers of public services
• INPUTS (well-trained personnel, equipment)
• PROCESSES (protocols, treatments)
• OUTPUTS (completed CABG, for example)
• OUTCOMES (increased life expectancy,
  quality of life)

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BS1036 Quality Management in the Public Sector
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BS1036 Quality Management in the Public Sector

• Notice the distinction between
• TRADITIONAL healthcare (quality is PRODUCER
  DEFINED)
• Empowered healthcare (quality is not only
  producer-defined but also consumer-evaluated)
• Distinctions can also be drawn between
• Standards and Charters (Patients Charter)
• Continuous Quality Improvement (USA
  experience)

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BS1036 Quality Management in the Public Sector

• DONABEDIAN Classic formulation of quality
• Structure (buildings, staff, equipment)
• Process (all that is done to the patient)
• Outputs (immediate results of medical
  intervention)
• Outcomes gains in health status
• Each end may be seen as the means to a further
  end so processes and outcomes are more
  interlinked (e.g. quality structures and quality
  processes are more likely to lead to quality
  outcomes)

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BS1036 Quality Management in the Public Sector

• DONABEDIAN Later formulation of quality
• the quality of technical care is defined not by
  what is done but by what is accomplished.
  Consumers are uniquely able to say what outcomes
  are to be pursued, what risks are to be accepted
  in return for what prospects of amelioration and
  at what cost
• What happened between late 1960s (classic
  Donabedian) and the late 1990s? (later)

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BS1036 Quality Management in the Public Sector

• MAXWELLs definition (1992)
• Effectiveness (achieve intended benefit)
• Acceptability (satisfies reasonable
  expectations)
• Efficiency (resources not over-supplied to
  some patients to the detriment of others)
• Access (those who need services receive
  them)
• Equity (Resources are fairly shared)
• Relevance (treatments are appropriate)

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BS1036 Quality Management in the Public Sector

• Varieties of audit
• Medical audit (by clinicians)
• Nursing (clinical) audit
• Multi-professional audit
• Consumer Audits (not well developed)
• Note also
• League Tables
• Patients Charter initiative

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BS1036 Quality Management in the Public Sector

• Joss and Kogan (Advancing Quality) undertook a
  systematic evaluation of the implementation of
  TQM into 19 pilot sites in the NHS (using also 2
  commercial comparators)
• No before/after evaluation
• Quality does not come free
• Majority of citizens had little to do with TQM
• Senior clinicians would be involved in
  quality issues if..
• pre-planned with key professionals
  (medical director)
• use of survey data from initial evaluation
  made clinicians more aware

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BS1036 Quality Management in the Public Sector

• Joss and Kogans analysis of the problems
• TQM is just one more initiative, and therefore is
  not TOTAL
• Frequent changes of policy are manifest
• There is a lack of investment finance
• The multi-professional nature of
  TQM(particularly acute in the NHS with a
  multiplicity of high status, well-trained
  professionals with high professional ethos)

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BS1036 Quality Management in the Public Sector

• Patient empowerment
• Is empowerment another contested
  concept?
• Empowerment often means empowerment for
  managers, not for front-line staff, patients
• Prime impetus behind this notion that most
  practices of patient satisfaction are flawed
  (happy sheets) because of methodological
  sloppiness, inadequate sampling, tick-in-the-
  box questiionnaires (i.e. producer-led)

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BS1036 Quality Management in the Public Sector

• Consumer-friendly approaches
• Consumers are consulted (interviews etc.) to
  ascertain those elements of the service to be
  measured
• Consumers engage in consumer audit (the
  application of qualitative research methods to
  find out what patients, carers and potential
  users think of health services and want from
  them)

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BS1036 Quality Management in the Public Sector

• Ecological approaches to quality (M. Hart)
• Attempt to measure quality not solely by
  quantitative means but by capturing the
  meanings imputed to episodes
• Examine the trajectories of medical care
  (i.e. series of linked sequences in which
  each episode is linked to prior experiences)
• Gain perceptions of all of the social actors
  (patients, all clinical staff, all reception
  staff etc)