Specifying quality in health care

Identifying Primary Care Pathways from Quality of Care to Outcomes and Satisfaction Using Structural Equation Modeling

OBJECTIVE

To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making.

DATA SOURCES

A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012.

STUDY DESIGN

Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care ("quality assurance," "education and training," "medicine management," "access," "clinical management," and "patient-centered care"), health outcomes ("intermediate outcomes" and "patient-reported health status"), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling.

PRINCIPAL FINDINGS

The model supported two independent paths. In the first path, "access" was associated with "patient-centered care" (β = 0.63), which in turn was strongly associated with "patient satisfaction" (β = 0.88). In the second path, "education and training" was associated with "clinical management" (β = 0.32), which in turn was associated with "intermediate outcomes" (β = 0.69). "Patient-reported health status" was weakly associated with "patient-centered care" (β = -0.05) and "patient satisfaction" (β = 0.09), and not associated with "clinical management" or "intermediate outcomes."

CONCLUSIONS

This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives.

Taiwan quality indicator project and hospital productivity growth

The Taiwan Quality Indicator Project (TQIP) is a quality management program that measures and monitors the healthcare quality of hospitals in Taiwan. This paper examines the impact of TQIP participation on hospital productivity growth with the application of the Malmquist productivity change index based on data envelopment analysis (DEA). Analyzing operations data from 31 TQIP regional hospitals over the period 1998-2004, we find that TQIP hospitals improved their productivity in the post-TQIP period. This improvement is attributable to quality change and relative efficiency progress. The simultaneous enhancement in both quality and relative efficiency coincides with the philosophy of total quality management (TQM) spirit, and confirms the efficiency improvement and quality assurance functions of TQIP.

Use of quality improvement methods in Finnish health centres in 1998 and 2003

OBJECTIVE

To evaluate how widely quality improvement methods are used in Finnish primary health centres and how the use has changed over five years.

DESIGN

Two national cross-sectional postal enquiries.

SETTING AND SUBJECTS

The questionnaire in 1998 was sent to every other physician graduated during the years 1977-1986, and the questionnaire in 2003 to every other physician graduated during the years 1982-1991. The response rates were 73.9% and 62.2%. The answers of primary healthcare physicians (n = 503 vs. 344) were analysed.

MAIN OUTCOME MEASURES

The availability of 13 quality improvement methods was solicited. The change over five years was analysed.

RESULTS

Opportunity to obtain continuing medical education (CME), in-service training, meetings, opportunity to consult a colleague in own speciality, and agreed guidelines on how a certain problem should be solved were highly reported both in 1998 and 2003. The biggest improvement (16.8%) concerned clinical guidelines. There was also progress with regard to quality improvement manuals at the place of work, opportunity to consult a colleague in another speciality, and computer-assisted monitoring of own work.

CONCLUSION

Many quality improvement methods were highly reported in both 1998 and 2003 in Finnish health centres. The biggest positive change concerns clinical guidelines.

New Zealand Polynesian women's access to information about cervical screening

Immigration by Pacific Island people into New Zealand has raised issues of equal access to a range of government and social services, including health information. This study reports on an investigation of access to information by women in Pacific Island cultures resident in Palmerston North. The New Zealand health environment is quickly changing and features market-style reforms, greater accent on privately-funded health schemes and an ideological shift in the direction of individual responsibility for one's health. We describe what we found to be the major impediments to quality of health information accessible by Pacific Island women and conclude with proposals for changes and developments in public health communications.