Understanding quality in health care.

When quality assurance/improvement is mentioned, nurses tend to think of endless audits, grim-faced auditors and harassed managers. So what has this really got to do with quality? Before considering this, it is worth reviewing the meaning of quality. Quality is "the ability of a set of inherent characteristics of a product, system or process to fulfill requirements of customers and other interested parties" or fit for the purpose or industry accepted practice. (1) This meaning is often a surprise; many think of quality as exceeding industry accepted practice. In New Zealand, quality assurance/improvement activities are "protected" by the Ministry of Health. (2)

Health care has been late in adopting quality. Only in the last 15 years have some health care providers chosen voluntary accreditation to quality systems. In 2004, the Health and Disability Services (Safety) Act required all licensed or registered health facilities to be certificated. (3) Facilities are audited by one of eight Director-General of Health's designated audit agencies (DAAs) against the Health and Disability Sector Standards(HDSS). Facilities can be awarded a one, two or three- year certificate or no certificate. Rather than being appointed by the Ministry, DAAs are contracted and paid by the facility they are auditing. This process risks claims of conflict-of-interest for auditors (4) and the perceived pressure to give a "good" audit result. Some district health boards (DHBs) commission third-party contractual or issues-based audits. The HDSS constitute the industry "accepted" standards for consumer rights, organisational management, pre- or entry to service; service delivery; managing service delivery; safe and appropriate environment; infection control; and restraint. Mental health care providers are audited using the national mental health standards. Similarly, DHB audits examine accepted clinical care.

The audit process identifies a standard, requests documentation to demonstrate implementation and triangulates with other evidence, eg facility inspection, care plans, staff/patient/relative/health professional interviews. A "technical expert" health professional audit team member should audit health care/patient aspects. As a consultant lead quality auditor working in a range of health care facilities, I have had the privilege of seeing fantastic quality management systems and interviewing excellent staff and grateful patients/families. But, I have also seen marginal, unscientific, neglectful and occasionally abusive patient care, given knowingly or unknowingly by registered health professionals and/or unregulated staff.

Limited understanding of quality

I have seen many health professionals who have an extremely limited understanding of what quality improvement can offer them and their patients, most having never received education in the philosophy or tools of quality improvement. Great facilities are characterised by leaders who commit to the philosophy of quality care and support staff in developing skills, supplying necessary resources. Quality does cost, but wise owners/managers know the cost of poor quality care is even greater in terms of poor patient outcomes/morbidity, reputation, staff attrition, patient dissatisfaction, complaints and diminished bed occupancy.

I have seen big and small, public and private health care facilities with well-developed quality systems, robust documentation, comprehensive and current care planning, proactive staff training, interdisciplinary involvement and patients/family entirely satisfied with care. I have also audited "large chain" providers which have beautifully crafted policies but have not provided time or resources to hands-on staff.

Quality improvement activities should be everyday activities, not just dusted off when auditors come to visit. A perfect example is the Liverpool Care Pathway quality improvement initiative, outlined on pages 12-15 of this issue. Assuring quality means the rote of registered nurses (RNs) must change in facilities where health care assistants (HCAs) are the main providers of care. The subtleties of a deteriorating clinical condition cannot be assessed by an HCA, nor interactions undertaken with distressed, anxious families or malicious complainants--these are RN responsibilities. RNs must be vigilant and skilled in providing oversight of HCAs: ensuring care plans are relevant, achievable, up-to-date and used; organising/delivering training; monitoring high-risk aspects; and providing the most critical aspects of care.

So what are the current tensions in delivering quality care?

Owners, managers and staff say they are not adequately funded to provide quality care. Not-for-profit health care providers are struggling with funding issues, often having older facilities and higher running costs and, as a result, are exiting the industry. Ironically, a number of the large for-profit organisations register huge sharemarket profits, although possibly not from the continuing-care hospital.

RNs working in aged and disability care are currently not valued for their clinical expertise. Lack of pay parity is forcing them to leave and work in settings governed by multi-employer collective agreements, which provide better pay rates.

All registered health professionals must enact their professional accountability for health care. It is not right to stand by and cry "poor staffing" or "I didn't know it was happening". A professional mandate is to speak out and report poor, abusive, neglectful care. Commendably, NZNO is attempting to establish benchmarks for safe staffing in the aged-care sector.

Potential auditor conflict of interest could be minimised by bodies such as the Ministry appointing (and directly paying) auditors.

Despite these specific tensions, I have observed that knowledge and implementation of quality improvement leads to committed staff and thoughtful, considered, safe and innovative patient care.

References

(1) Standards Australia/Standards New Zealand International Standards Organisation (ISO) 9000:2000

(2) Ministry of Health (2004) Protected Quality Assurance Activities under the Health Practitioners Competence Assurance Act 2003. http://www.moh.govt.nz/moh.nsf Retrieved 23/02/07.

(3) Health and Disability Services (Safety) Act. (2004) http://www.moh.govt.nz/moh.nsf/wpg_Index/ About-Health+Service+Providers+System+Certification. Retrieved 18/02/07.

(4) National Ethics Advisory Committee. (2006) Ethical guidelines for observational studies: observational research, audits and related activities. Wellingto: Ministry of Health. http://www.newhealth.govt.nz/neac/ethicalguidelines.htm. Retrieved 24/02/07.

Eileen McKinlay, RN, MA (Appl), is a lead quality auditor. She is also a senior lecturer in primary health care at the Wellington School of Medicine and Health Sciences.