What is quality?
I have thought about this and reflected on how many times I have been asked to prove the quality of care. 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.
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.
Quality is dynamic and requires discussion, decisions, and sometimes a little disruption. This is why I am here on this forum.
Quality is multi dimensional with multiple layers with multiple meanings. I have worked at these layers and notice the links, and the gaps.
I shall give two examples.
I recently worked with the MoH in Zambia working with the team to define quality and design the national approaches needed. We needed to do more than prove what was happening, we needed to improve it. This national quality improvement approach was helped by the WHO quality strategy documentation and these eight points become the foundation of the work.
From this we could measure much of what was defined as quality. This now links up with the latest WHO documents. [*see note below]
Now in 2021, with the lastest WHO documents we can build on these foundations and count each level we work at, and each clinical encounter we have.
And the gaps.
On a personal level, my clinical encounters over the weekend have had quality at their core too. The weekend's approach to quality needed not just the infrastructure to make sure our environment was safe and our evidence that was sound, we needed empathy too. The patients could only see our eyes and some were scared. For the patients before me quality was in the relationship we formed in those brief moments together as much as the care performed. The skills, or 'agency' needed to make each of these contacts count as quality for all parties involved can be seen as a competency, I see it more as human compassion. This is also part of quality. But there is no need organisationally to prove it.
In sociological theory the linking aspect between infrastructure and agency is called capital, and this for me is where a culture of quality comes in.
Somehow the intangible invisible glue linking skills and structure, is the quality element we also need. For me this includes personal habits of being conscientious in our work and kind in our words. This includes an organisational culture that values its staff as much as its statistics. A system that wants to improve quality as well as prove quality, and supports staff to do it. The gap for me is how we value this.
The latest WHO work enables us to measure what matters and improve quality as well as prove quality, thereby providing the care needed to improve health experiences and outcome.
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.
Dr Marion Lynch
HIFA profile: Marion Lynch is a global health consultant and nurse with nearly 40 years of experience in international health service design and education. She has a Doctorate in Health Science and a Visiting Professor in with University of West London. Marion has designed and delivered Masters level quality improvement programmes within the NHS in the UK and led the 2021 THET conference stream on compassion. She is a member of the HIFA Catalyst Group on Learning for quality health services.
[*Note from HIFA moderator (Neil PW): Thank you Marion for this valuable exploration. The two documents to which Marion refers are:
1. Quality health services: a planning guide (2020)
2. WHO Fact Sheet on Quality Health Services (2020)