Customer Support -- Discussion

Quality Domains

Quality Domains

Quality is classically very difficult to define and in many ways is best perceived and judged through the experiences of our "customers".

Debate on the definition of customers of a healthcare system system is common and contentious with fierce debate eg whether patients should be called customers, clients, or patients. Many other groups of people may be considered as "customers" including commisioners, health authorities, government, communities and carers. This makes the definition of quality even harder.

One of the problems of defining quality is that if the definitions do not resonate with staff, patients and other "customers" then achieving and sustaining quality improvement is extremely difficult. We have frequently debated quality at many of our meetings and in particular during the networking that occurs around meetings. A recurring theme has been that many of the current definitions of quality have not resonated with us. Late night discussions and debate have slowly resulting in the following quality domains emerging repeatedly and that these do seem to resonate with both staff and patients. Please consider these and join the debate.

Domain	Description	Strategies (draft)	Monitoring (draft)
Consistent	Similar patients treated similarly	Protocols, care pathways, care bundles, “right skill, right time, right place”, equitable care
Predictable	Planned or scheduled	Full-booking, treatment templates	% full booking for all stages of patient journey, % template match
Timely	No unnecessary waits/delays/waste; timing matches disease & patient requirements	Value-added, realistic service planning and utilization, reduction of variation, step reduction	Access targets, LOS, referral to completion-discharge
Reliable	Occurs as planned/scheduled, error-free	Realistic service planning and utilization, reduction of variation, working resource “slack”	Cancellation rates, error rate
Effective	Appropriate outcomes and error-free	Appropriate choice of treatment, appropriate treatment delivery, appropriate care, audit & governance, “managed service”	Mortality, morbidity, readmission rates, survival, disease free survival
Acceptable	Patient-focused, “the patient experience”	Communication, symptom management, tailored, dignified, environment, choice, recognizes diversity	Patient survey
Informed	Informed care	Information leaflets, shared care, patient held records, patient advocacy, communication, true informed consent	Complaints, consent process

You may notice that there is no entry for cost-effectiveness or value for money. A recurring feature was that for many staff and patients in the UK NHS there was an extremely strong perception that cost-effectiveness as a specific domain leads to improvement measures that are aimed to save money often perversely at the expense of quality. Rather most believed that by achieving the seven domains listed, then cost-effectiveness and value for money would inevitably result to a much greater and sustainable effect.

The last two columns are very early attempts to start developing strategies and monitoring approaches that can be incorporated within a quality improvement framework.

If you have comments or suggestions please either join the health design email discussion group or alternatively email qualitydebate@steyn.org.uk (emails to this address will not generate a reply but will be appreciated and considered).