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ANALYSIS: Glyn Elwyn, Stephen Buetow, Judith Hibbard, and Michel Wensing Respecting the subjective: quality measurement from the patient's perspective BMJ 2007; 335: 1021-1022 [Full text]

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Prisoners as patients: assessing quality of prison health services

Niyi Awofeso   (19 November 2007)

Letter to the editor

andrea d de Visser   (7 September 2008)

Prisoners as patients: assessing quality of prison health services 19 November 2007
Niyi Awofeso, A/Prof. School of Public Health and Community Medicine University of New South Wales, Sydney 2052, Australia. Send response to journal: Re: Prisoners as patients: assessing quality of prison health services	Quality in health may be defined as doing the right thing, the first time, in the right way, and at the right time with regards to improving health status and prolonging life.1 Prisoners’ input into the assessment of the quality of prison health services is complicated by penal populism and disputes over funding sources for the relatively more costly health requirements of individuals that end up on the wrong side of the criminal justice system. Three main ways by which patients’ (prisoners’) perspectives might influence the measurement of quality of prison health services are surveys of patients’ assessment of quality of health services provided2, surveys of patients’ assessment of their priority health needs3, and litigations by patients demanding adequate health care.4 Despite the use of such approaches by prisoners and custodial health authorities, the health status and outcomes of prisoners in most countries worldwide remain unsatisfactory. Litigations by prisoners have generally been counterproductive, invariably leading to legislation to further limit prisoners’ access to health and services and reduced opportunities for legal redress.5 As Elwny et al point out in relation to patients in community settings6, incorporating prisoners’ perceptions on quality of prison health services into prison health quality assessment and improvement strategies is a necessary but not sufficient approach to improving correctional health care. The reality of limited prison health care funding and rising prisoner health care needs underline the need for prisoners to have an input into how available finite resources may be utilized efficiently for their (and ultimately the community’s) benefit. References 1) NSW Department of Health. Easy guide to clinical practice improvement. 2nd edition. Sydney, NSWHEALTH, 2002. 2) Barling J, Halpin R, Levy M. Capturing perceptions: prisoners assess their health services – Australia, 2001 and 2004. Int. J. prisoner Health, 2005. 3) Smith C. ‘Healthy prisons’; a contradiction in terms? Howard J Crim Justice 2000; 39: 339-53. 4) Estelle v gamble, 429 US 97, 102 (1976). 5) Awofeso N. Prisoner healthcare co-payment policy. App. Health Econ. Health Policy, 2005; 4: 159-164. 6) Glyn E, Buetow S, Hibbard J, Wensing M. Respecting the subjective; quality measurement from the patient’s perspective. BMJ, 2007; 335: 1021- 2. Competing interests: None declared
Letter to the editor 7 September 2008
andrea d de Visser, Associate Nurse Unit Manager 3805 Send response to journal: Re: Letter to the editor	To the Editor: I would like to comment on the article ‘Respecting the Subjective: Quality Measurement from the Patient’s Perspective. As outlined in the composition interest in quality assessment activities is again on the incline, stimulated in part by concerns that the cost-containment policies of the early 1980’s were implemented with little trepidation to their effects on the future of quality of healthcare services. Today’s competitive healthcare industry has an astute focused attention on quality, as providers seek to improve their services in an attempt to distinguish themselves from their contenders. As discussed by the author, there is renewed attention to the consumer’s viewpoint, and their role in quality improvement, which raises the question: Can patients provide authenticate data about the quality of their healthcare? The article highlights patient’s viewpoint as a measure of quality improvement, one that is gaining importance and is used by many health organisations as an evaluation on the basis of care delivery. The writer goes on to identify this measure as a complex entity dependent on several variables which the patient plays a central role in managing. One disappointing feature of this article is that it fails to define what a measure is in the context of healthcare. Also I would like to dispute the validity of the patient’s perspective as a true measure, one that is not without bias. Quality in health care is the main subject matter of public regulation in many countries and extensive policy debates globally, suggesting that policy makers deem patients, alone unqualified, to ensure high quality care is met. Nonetheless authors, such as the writer pertaining to this discussion, commonly assume that patients know about the quality of care available from different providers. Furthermore, the information patients have and how they came to possess it is not specified in the article. Firstly, quality of care can be measured. The critical challenge is to select measures that are inducing to key stakeholders. This is a necessary first step if quality is to be routinely taken into account in making decisions by key participants in the health care industry. The author falls short in outlining the criteria for selecting such measures. Quality measures in healthcare generally consist of a descriptive account or indicator (e.g., the rate of beta blocker use after a heart attack), a list of data elements that are necessary to construct and report the measure, detailed specifications that instruct how data elements are to be collected (including the source of data), the population on whom the measure is constructed, the timing of data collection and reporting, the analytic models used to construct the measure, and the design in which the results will be presented ( Tomlison, 2006). Furthermore, four sets of criteria are commonly used to evaluate potential quality measures: they must be important, scientifically acceptable, usable, and feasible. These four sets can be seen as a hierarchy for assessing measures ( Tomlinson, 2006) In addition, a measure is scientifically acceptable if it produces consistent and credible results when implemented. Much of the scientific acceptability of a measure can be determined through design and appropriate use. The elements of scientific unassailability are: (1) precise specifications, (2) reliability, (3) validity, (4) adaptability, (5) adequacy of risk adjustment (6) inclusion of explicit conditions of use ( Mc Glynn, 2003). The mechanism for identifying prospective measures with the greatest potential to stimulate improvement on a national goal uses the evidence base to choose a small number of appropriate measures. However, to get the greatest advantage from this process, the data necessary to ascertain performance on an influential level must be readily available throughout the health care system ( Mc Glynn, 2003). The importance of quality in the health care sector has been recognised fairly recently, but it has accelerated over the years through the development of quality assurance and quality improvement programs. Furthermore, quality is prevalent in the marketing literature where the notion of satisfying the customer is a dominant model of quality of service imparted and consumer satisfaction. This movement has initiated a global research with over 15,000 articles published on assessing customer satisfaction. However, Locker and Dunn were among the first who pointed to a lack of theoretical groundwork for the concepts of patient satisfaction and perceived quality of care provided. Quality of care from the patient’s perspective and patient satisfaction are two major multidimensional concepts that are used several times interchangeable in the article. In agreement with the author, yes quality of care has a subjective profile. However, it also involves a cognitive evaluation process and objective determinants in which care is the outcome. Consumer rating scales on quality of care correlate with individual’s attitudes toward the community, satisfaction with life and values or expectations regarding medical services also combining with health status and with educational level, age, income, ethnicity, and geographic location. Because consumer ratings or patient satisfaction scales do not contain information about the consumers, the validity of evaluation of health care is questionable ( Raftopoulos, 2005). Furthermore, the evidence from consumer ratings or patient surveys is difficult to interpret, given that we know little about the relationship among these factors, as discussed above. Ratings should reflect information solitary about attributes of health care and thus any relationship between these ratings and other characteristics indicates bias ( Raftopoulos, 2005). It could be stressed that the satisfaction or dissatisfaction of patient’s health care needs results in experiencing certain feelings or emotions. Generally speaking it is assumed that the discrepancy of a need yields positive feelings, whereas the dissatisfaction of a need generates negative emotions. Also if a need is not satisfied then the related negative feelings will stimulate a drive to gratify this need. This depends on the temperamental component of a patient’s value system indicating that individual personality traits such as emotional status are directly associated to satisfaction because they represent affective dispositions. Furthermore, pseudo-satisfiers may stimulate a false sensation of satisfying a certain care need, but they may in fact impede the fulfilment of that need ( Mcglynn, 2005). Lastly, let us use the Hawthorne effect to explain patient satisfaction and quality. The term was proposed in 1955 by Henry A. Landberg. Landsberg defined the Hawthorne effect as; a short-term improvement caused by observing worker performance. The Hawthorne effect states that quality will improve whenever there is change in one’s environment. Also, the Hawthorne effect is a form of reactivity and describes a temporary change to behaviour or performance in response to a change in the environmental conditions, with the response being typically an improvement. When applied to health care, the Hawthorne effect, gives evidence of sensitivity to quality suggesting that patient’s beliefs about quality may be responsive to their experiences, particularly when they witness significant changes in quality. The Hawthorne effect may therefore offer a view of the impact of behaviour on outcomes even when behaviour and outcomes are partially determined by unobservable characteristics of exchange ( Leonard, 2008). In summation patient’s satisfaction represents a global cognitive evaluation or judgement of their satisfaction with quality of care provided. Patient’s satisfaction can be viewed as a summary evaluation of care episodes ranging form positive to negative. In other words, satisfaction is an attitude of one’s liking or disliking of healthcare provided. This emphasises the role of broad individual differences in personality in satisfaction, and the role of certain situations, events, during hospitalisation or during pervious use of healthcare services in overall satisfaction with care given. Several aspects of patient’s personality affect the way they consider the care environment. Measuring and reporting on patient satisfaction with health care has become a major industry. Compared with measures of technical quality (e.g. appropriateness criteria or adjusted outcome models), data on patient satisfaction vary widely. The only way to determine what patient’s want and whether their needs are being met is to ask them. From this perspective, viewing care ‘through their eyes’ is an ethical and professional imperative Health organisations are operating in an extremely competitive marketplace and patient satisfaction has become key to gaining and maintaining market share. All major players in the health care arena use satisfaction information when making decisions. Also because much satisfaction data reflects care delivered by physicians and other provider groups, this information is receiving close attention from consumers, employers and accrediting organisations. The scrutiny is based on data collected which may or may not accurately reflect the care delivered by individual provider groups. Moreover, focusing on patient satisfaction averts attention from what should be our principle concern. As healthcare communicators we should consider giving patients what they need to make sound decisions and choices about their healthcare. Tracking and reporting meaningful and valid measures of quality is one way to do this. References: 1. Leonard, K. Is Patient’s satisfaction Sensitive to Changes in the Quality of Care? An Exploration of the Hawthorne Effect: Journal of Health Economics 1998; 27: 444- 459 2. MyGlynn, E. Medical Care: Official journal of the medical care section, American public health association 2003; 41: 1-39- 1-47 3. Raftopoulos, V., RN, MBA, PhD. A Grounded Theory for Patient’s Satisfaction with Quality of Hospital Care. Incus Nurs Web J 2005; 22: 1- 15 4. Tomlinson, J.S. MD. Patient Satisfaction: An Increasingly Important Measure of Quality: Annals of Surgical Oncology 2006; 13: 764-765 Competing interests: None declared