Quality assurance frameworks

Citation

Hurst, K. (2005), "Quality assurance frameworks", International Journal of Health Care Quality Assurance, Vol. 18 No. 6. https://doi.org/10.1108/ijhcqa.2005.06218faa.001

Quality assurance frameworks

There’s a danger that I could resurrect a stalemated debate about whether health and social care professionals work with quality assurance models or theories. In short, models define and explain while theories test and develop knowledge. Quality assurance frameworks (a less troublesome synonym) are invaluable skeletons on which to hang QA policy and practice issues. They help writers and readers to organise their thoughts and actions such as quality standards and ensure that their QA activities are coherent. There is a great choice of frameworks and there are horses for courses. Most readers will be familiar with enduring frameworks such as the quality spiral: setting standard; comparing services against standards; and raising the game or standards depending on the audit outcome (Hurst, 2002, p. 12). Similarly, Donabedian’s structure, process and outcome triad and the Maxwell/Shaw 3A&3E variants – access, acceptability, appropriateness, equity, economy and effectiveness (Maxwell, 1992) – not only help practitioners underline service quality elements but also prompt them to raise audit questions to test how well quality standards are being met. Recent additions to the QA framework stable are becoming front-runners. Indeed, following an extensive analysis of QA and related articles in the Emerald Insight database (see www.emeraldinsight.com) the most frequently used QA frameworks were a combination of stalwarts and young bloods:

• •

  Continuous Quality Improvement (22 per cent);

• •

  Balanced Score Card (21 per cent);

• •

  European Foundation for Quality Management Business Excellence Model (16 per cent); and

• •

  audits and questionnaires based on Maxwell/Donabedian (16 per cent), etc.

There were, on the other hand, a number of frameworks “borrowed” from non-health disciplines, which worked equally effectively. One lesson learned from my review was that choosing the right framework deserves more than a little thought.

As readers will see, authors in Vol. 18 No. 6 use a range of well-known and emerging QA frameworks. In stage 1 of their important Portuguese study, Eiriz and Figueiredo look at broader customer expectation and satisfaction theory and practice before applying them to healthcare. They carefully unravel internal customer (health carer) and external customer (patient) expectation and satisfaction in Portugal’s increasingly competitive health service. Their analytical approach to defining and measuring quality outcomes help them to complete what most of us have found to be a challenging task. Readers, I’m sure, will look forward to their stage two results.

Sivabrovornvatana and her Thai colleagues write about an up-and-coming QA issue: e-quality (a subject about which readers will see more in future issues). Their exploratory work concentrates on the relationship between healthcare quality management systems (QMS) and health service information management and technology (IM&T). They measure internal and external customer satisfaction using IM&T as the backcloth. Interestingly, they briefly compare the Nordic school of service functional and technical elements (Grönroos, 1982) with Parasuraman’s five SERVQUAL dimensions:

1. 1.

   reliability;

2. 2.

   responsiveness;

3. 3.

   assurance;

4. 4.

   empathy; and

5. 5.

   tangibility (Parasuraman et al., 1988).

They use the latter to great effect. Because QA theory and practice are developing, readers won’t be surprised that these authors generate new insights that have at least service management and practice implications. In another article, Smith also underlines the connections between IM&T and quality management, but in this case North America. His subject and approach – e-procurement and e-commerce – are unusual but important for health care. A range of technologies are examined for the way they enhance and inhibit health care efficiency and effectiveness. Internet commerce breakdowns and solutions are discussed, along with how they affect and involve managers and clinicians. Importantly, the author seamlessly applies several performance frameworks originating outside health and social care.

Simonet returns to the patient expectation and satisfaction theme, but in a North American managed care context – specifically comparing traditional fee-for-service (FFS) with health maintenance organisations (HMOs). Readers are treated to a deep and wide systematic review of managed care patient expectation and satisfaction. As well as generating new service quality considerations, fascinating discussions are raised during his meta-analysis, which resurrect long-standing debates such as patient choice that are worthy of his deeper inquiry.

Friesner and his colleagues examine a service quality item on which my IJHCQA colleagues and I would like to see more written – physical and related therapies. They use a quantitative management science performance technique called data envelope analysis (DEA) to measure North American hospital joint replacement rehabilitation therapies. Their implicit QA framework is Donabedian’s structure, process and outcome, and despite honestly reporting sampling and psychometric problems, their simple and precise outcome definitions are elegant. Warburton writes a follow-up article to one published last year in IJHCQA (Warburton et al., 2004) on chronic disease management (CDM) in the elderly – notably unnecessary in-hours and out-of-hours care (a growing issue in several countries). The article is primarily an economics (cost-benefit and senstivity) analysis of important Canadian health and social care issues and related services. However, readers will also be interested to see how she uses the plan-do-study-act (Leebov and Scott, 1994, p. 128) framework to evaluate the team’s work and keep this longitudinal project on track.

Clearly, QA frameworks, even though they may be implicit, are alive and well. Here are some good examples covering not only borrowed frameworks from outside health but also enduring and up-and-coming ones specific to health and social care. Hopefully, readers will benefits from reading not only the articles’ quality improvement recommendations, but also the QA frameworks in which they are placed.

Keith HurstNuffield Health and Social Care Policy Group, Health Sciences and Public Health Research Institute, Leeds University, Leeds, UK