Are health service targets useful?

Citation

Hurst, K. (2013), "Are health service targets useful?", International Journal of Health Care Quality Assurance, Vol. 26 No. 3. https://doi.org/10.1108/ijhcqa.2013.06226caa.001

Are health service targets useful?

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 26, Issue 3

Health service targets have never been popular with managers and practitioners. Nevertheless, waiting times, for example, have reduced significantly in the UK after the “18 week Referral to Treatment Time” (RTT) target was established. There are powerful incentives that encourage managers and practitioners to ensure that waiting times are achieved such as, in the UK, losing a “star” in the English NHS service quality rating system. Consequently, Claire Greaves and colleagues in this issue describe a Patient-focused Care/Business Process Re-engineering method that underpins a project aimed at reducing waiting lists in a highly-specialised but important diagnostic service. Their article has several important messages: fully understanding the problem before solutions are implemented; engaging staff in an interdisciplinary fashion; paying special attention to service skill mix; and remaining sensitive to change-management dynamics. Their efforts had a remarkable service-impact;, e.g. waiting times fell from 42 to two weeks and probably just as important, staff remained “on board”.

Health service target achievement partly depends on how we define healthcare quality – a Holy Grail – which is never easy owing to healthcare’s intangibility compared to, for example, manufacturing service quality. Customer satisfaction, owing to its importance, has to feature in any public service-quality definition or at least the subtext. One problem, however, is that QA experts feel that patients cannot judge technical quality because they do not have the knowledge and skills (which at least one article in this issue questions). Nevertheless, healthcare quality assurance theory and practice moves on, so it’s important to take stock regarding how authors define and operationalise healthcare service quality. In this issue, therefore, Ali Mosadeghrad undertakes an extensive healthcare-literature review and explores service-quality definitions using focus groups and interviews. The article’s groundbreaking feature is that empirical work takes place in Iran; thereby giving the definitions a distinctive middle-east focus. The author underlines how complex and comprehensive healthcare service quality definitions are, not least because stakeholders have different perspectives. Despite the topic’s complexity, Dr Mosadeghrad is able to generate a neat “Eight Rights” framework, which we can use to think about and act on healthcare quality.

Can we use non-health service improvement techniques in healthcare to help managers improve efficiency and effectiveness generally and targets specifically? One approach – Lean (Toyota Production System) – is steadily gaining ground in healthcare, so in this issue Nicola Burgess and Zoe Radnor examine Lean’s structure, process, outcomes and outputs in the English NHS. Their health and business literature review defines the Lean approach and explains its intentions in healthcare. Their two-stage, qualitative and triangulation approach adds new and important insights into Lean’s implementation healthcare. Although the Time 2 evaluation shows improvements compared to Time 1, which are encouraging, the authors admit there were disappointing outcomes, which could not always be explained; hence their call for case-studies that look at successful and unsuccessful Lean health-service organisations.

Patients are more informed and discerning about the services they receive. Unacceptable waiting times, as health service targets, are likely to be one reason why patients switch from public to private health services, so does satisfaction influence patient loyalty (something that’s less blindingly obvious than it seems). Dissatisfied patients switching service-providers is likely to be far more complex and probably involves several variables. So, what do we know about service-switching and tolerance zones (what low service-qualities are patients likely to tolerate). In this issue, Rooma Ramsaran-Fowdar (a regular contributor to IJHCQA) looks at these issues using the broader literature generally and Parsuraman and colleague’s SERVQUAL instrument specifically. The switching barrier list generated from the non-health and health literature is surprisingly long. And if they are exposed to health service providers and user review then findings are surprisingly complex. However, the author’s illustrations are helpful and interesting, which offer service providers several ideas for improving patient loyalty – notably interpersonal relationships.

For economic reasons, maternity care – two good outcomes for one input and its long-term economic impact places it among the most important health services we offer. In this issue, Edward Broughton and colleagues describe an interesting and significant maternity service quality intervention (sharing best-practice knowledge and skills). Niger is the focus (among the areas with the highest maternal mortality). The authors’ main aim was to assess the QI project’s economic value if it was rolled out after the intervention showed improved outputs and outcomes, and lower costs (20 per cent). The authors rightly claim their study to be ground-breaking not least because their economic evaluation is detailed and because the new service structure, process, outcomes and outputs can have a significant impact on maternity service efficiency and effectiveness. The authors honestly report their study’s limitations, which can be addressed in follow-up work.

We’ve seen in previous IJHCQA-publications that patient satisfaction is a complex outcome that’s sensitive to wide-ranging variables from pain control to hotel services, which are briefly reviewed in this issue in an orthopaedic surgery context by Enda Kelly and colleagues. But is patient satisfaction partly dependent on patient compliance with post-operative instructions? If patients do not comply with medical, nursing and therapy guidelines and their outcomes are worse (e.g. complications and poor outcomes liked reduced mobility following hip replacement) then patient satisfaction is an important issue especially if we wish them to remain loyal customers. If we take extra measures (an explanatory brochure in this cases) to inform patients in detail about surgery procedures then are outcomes improved; i.e. are cost benefits greater for a relatively small intervention? Does informing patients about post-operative procedures and realistic expectations hinder or help? Telephone interviews with patients undergoing hip replacement up to 30 months ago shows they have remarkable recall about what was explained and what instructions they were given. Although the high patient-satisfaction and low complication rates among the study cohort cannot be directly attributed to the instruction booklet (because this study wasn’t an RCT or CCT), at least the findings open avenues that can be explored. However, the study, on the other hand, generates new insights from the patients’ perceptions, e.g. users were dissatisfied with reduced physiotherapy at the weekend and that some patients ignored important advice such as not driving for six weeks after hip replacement surgery.

Choose and Book (or another country’s equivalent) allows patients to pick a service provider they prefer. Without robust health service measures, however, service-choice is guesswork (although word-of-mouth, remains a strong driver). So, how valid, reliable and transparent are health service performance indicators (PIs) that patients use to judge service quality? For example, if hospital structures, processes, outcomes and outputs aren’t measured in the same way then what value are they to patients? Jaap van de Heuvel and colleagues explore these vexing questions in this issue. They review healthcare and commercial (mainly accountancy) PI literature to summarise PI strength and weaknesses before offering a framework and related guidance in which professionals can think about and act on healthcare PIs.

Keith Hurst