Quality (125) What does quality of care mean to you? (36) Improving the quality and safety of health services (9)

11 July, 2021

Dear Marion,

In my humble opinion this is the best vision of “What is Quality?” so far. Apologies for not commenting earlier. I recommend everyone consider Marion’s thoughts. [ https://www.hifa.org/dgroups-rss/quality-62-what-does-quality-care-mean-... ]

I have added my comments into you words in CAPITALS.

AND NOW THAT I HAVE FINISHED, PLEASE EXCUSE MY SOMEWHAT OVERWHELMING TREATMENT OF YOUR COMMENT.

Regards,

Mark Cantor

Marion Lynch, UK

on June 28

Reply

What is quality?

I have thought about this and reflected on how many times I have been asked to prove the quality of care.

THINKING IS ONE OF THE BIGGEST CONTRIBUTORS TO QUALITY. TURNING INWARDS AND THINKING ABOUT WHAT WE DO WHAT OUR ORGANISATION DOES AND PONDERING CAN IT BE BETTER?

I have measured the quality with the agreed quality metrics of the day. I have completed the organisational matrix recording the answers to the questions 'how many interventions?' and 'how much contact time?'. I look back on this and wonder, did we ask 'how may it be better next time?' Sadly I confess, not very often and not very loudly. We got on with recording and reporting and repeating what we had done the day before. That is not Quality.

SO SO SO TRUE! THE AGREED METRICS ARE TYPICALLY HIGH LEVEL, EXECUTIVE AND MINISTERIAL. I’VE EVEN HEARD EXECUTIVES SAY “WE WANT TO BE IN THE MIDDLE, NOT TOO LOW, BUT ALSO NOT TOO HIGH AS TO DRAW ATTENTION”. VERY FEW OF THESE METRICS PROVIDE ANY INFORMATION AS TO WHAT NEEDS TARGETING FOR INVESTIGATION AND IMPROVEMENT.

“REPEATING WHAT WE HAD DONE THE DAY BEFORE” THIS IS THE DAILY CYCLIC TRAP. NO ONE CAN IMPROVE QUALITY WITHOUT CHANGE. YOU CAN’T JUST DO BETTER! PEOPLE, INDIVIDUALS, TEAMS, EQUIPMENT AND PROCESSES ALL OPERATE AT A STATISTICAL RELIABILITY. YOU CAN CHANGE SOME OF THOSE RELIABILITIES WITH TRAINING, BUT MOST QUALITY IMPROVEMENT COMES FROM CHANGING THE PROCESS.

Quality for me is asking that final question, asking it, reflecting on it, and then acting on the answers. And asking and improving it all again.

A MINDSET OF ANALYSIS, INTROSPECTION, UNDERSTANDING, CONTINUOUS IMPROVEMENT AND A FORMALISED PROCESS. CONTINUOUS IMPROVEMENT MUST BE A FORMALISED, DOCUMENTED AND APPROPRIATELY RESOURCED FUNCTION OF ANY SUCCESSFUL ORGANISATION. I NEVER EVER SEE HEALTHCARE STAFF THAT ARE DEDICATED TO THIS. IN INDUSTY THERE ARE USUALLY DEDICATED PERSONNEL TO ACT AS A CATALYST AND TO DRIVE CHANGE. IN MOST LARGE ORGANISATIONS, THAT IS WHAT ENGINEERS DO. THEY USUALLY SIT TO THE SIDE OR IN A MATRIX ORGANISATION AND SUPPORT PRODUCTION. SIMILARLY IN THE NAVY, THE LINE OF COMMAND NEVER INCLUDES THE ENGINEERS.

Quality is dynamic and requires discussion, decisions, and sometimes a little disruption. This is why I am here on this forum.

AGREE WHOLE HEARTEDLY, BUT IT MUST ALSO BE CONTROLLED. MANY MAN MADE DISASTERS HAVE OCCURRED WHEN SOMEONE HAS CHANGED SOMETHING, THINKING THEY WERE MAKING IT BETTER. WHEN THEY DIDN’T REALLY UNDERSTAND WHAT THEY WERE IMPACTING. ALL HIGH RISK INDUSTRIES HAVE CHANGE MANAGEMENT PROGRAMS THAT PROVIDE A REVIEW AND APPROVAL PROCESS FOR ANY CHANGE. THE EQUIVALENT OF A DOUBLE BLIND TRIAL, I SUPPOSE, DEPENDING ON THE RISK LEVEL.

Quality is multi dimensional with multiple layers with multiple meanings. I have worked at these layers and notice the links, and the gaps.

QUALITY IS EVERYTHING THAT SUPPORTS THE FINAL INTERACTION WITH THE PATIENT. MY UNDERSTANDING OF THIS COMMENT IS WHAT I KNOW AS “SYSTEMS THINKING”. EVERY SINGLE OUTCOME IS A RESULT OF PREVIOUS ACTIONS. UNDERSTANDING THE RELATIONSHIP BETWEEN ALL VARIOUS FACTORS THAT INFLUENCE AN OUTCOME.

THE “ROOT CAUSE ANALYSIS” I’VE SEEN IN HEALTHCARE IN DRIVEN BY LAWYERS, NOT A DESIRE FOR IMPROVEMENT. THE STATEMENT: “NO ROOT CAUSE FOUND” IS AN INSULT TO EVERYONE AND ABSOLUTELY DISGUSTING WHEN RELATING TO A FATALITY.

I shall give two examples. [... *see note below] Perhaps quality is the less visible capital, culture and compassion as well as the visible policies, plans and projects. We know all of these count to our patients, some more than others. With the help of WHO we can now make sure they can all be counted too.

CULTURE IS THE TOUGHEST THING TO CONTROL AND EVERYTHING HERE IS CULTURE. I HAVE NEVER WITNESSED A TRUE CHANGE IN CULTURE AND I BELIEVE IT HAS TO COME FROM THE VERY TOP. I HAVE DONE A LOT OF STUDY ON HIGH RELIABILITY ORGANISATION THEORY (HRO) AND THIS WAS HOW I BECAME INVOLVED AS A HEALTH CONSUMER REP.

YOU MENTIONED SOCIOLOGY. CAN I RECOMMEND THE WRITINGS OF A GENTLEMAN, PROFESSOR ANDREW HOPKINS.

https://www.processsafety.com.au/what-led-professor-andrew-hopkins-to-wr...

https://www.safeworkaustralia.gov.au/media-centre/use-and-abuse-culture

I HAVE HEARD THE HRO TERM USED SO MANY TIMES IN HEALTHCARE BUT THAT IT WHERE IT ENDS.

https://www.processsafety.com.au/books/learning-from-high-reliability-or...

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HIFA profile: Mark Cantor is a Health Consumer Representative and is based in Australia. He is a HIFA catalyst for the WHO/HIFA project on Learning for Quality Health Services. markacantor AT me.com

[*Note from HIFA moderator (NPW): I have taken out some paragraphs from Marion's original message. The full text is available here https://www.hifa.org/dgroups-rss/quality-62-what-does-quality-care-mean-... ]