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Shah indeed makes a good point in that we need to consider more than one perspective when attempting to understand what quality is, then look at ways in which we can measure it, and finally find ways to give those measures meaning, with a view to improving (the quality of) patient care. The 'how' to achieve this is indeed a challenging question, not least because, we need to agree not only on what we need to measure, but more practically, what we actually are able to measure.
Quality is a concept that can be hard to define, especially in a healthcare context. While we may agree on what it is not, it is harder to agree on an objective definition of what it actually is, as well as how we can link available data to it. It is also important that we keep the focus on quality improvement, not on performance targets and accountability. The Donabedian model and its dimensions of care (structure, process and outcome) remain as insightful as when first proposed over 50 years ago (Donabedian Evaluating the quality of medical care. Milbank Memorial Fund Q. 1966; 44(3) (suppl):166‐206), and still remains a leading framework in respect of evaluating the quality of healthcare. However, while other conceptual models have also been developed, none have allowed us any closer to the main goal of understanding the factors that contribute to good quality healthcare services, and how we can affect them to improve quality of care.
Highlighting the importance of qualitative data as the source of patient inclusion to identify factors that they see as contributing to better quality care is vital if we are to join up the ‘what we need to measure’, with the ‘what we are actually measuring’. If we are to move towards giving patients more of a voice in improving the quality of their care, this can only be achieved via in-depth analysis based on qualitative data.
Indeed we are now seeing a renewed interest in the importance of qualitative data. Since Pope et al published in 2002 (Pope C, van Royen P, Baker R Qualitative methods in research on healthcare quality BMJ Quality & Safety 2002;11:148-152), not including the first month, the number of times per month their paper was accessed gravitated around 20-60 until March 2017, when it increased steadily to approximately 500 in February 2019 (https://qualitysafety.bmj.com/content/11/2/148.altmetrics).
To ensure that we really are getting to the themes necessary to generate evidence to answer the ‘how’ and’ why’ questions, needed to feedback and guide quality improvement, then we need training of healthcare practitioners to increase their knowledge and skills regarding selection of research design. Cross-disciplinary collaboration and inclusion of those with experience of qualitative health services research, should also lead to richer data, and should be encouraged (Williams V, Boylan A, Nunan D. Qualitative research as evidence: expanding the paradigm for evidence-based healthcare. BMJ Evidence-Based Medicine Published Online First: 08 March 2019. doi: 10.1136/bmjebm-2018-111131).
Finally, and maybe most importantly, findings must be acted on and the measurement for quality improvement practices become standard in the training of healthcare professionals and in the running of healthcare organisations. Otherwise we risk measuring for measuring’s sake, and not using the data for improvement in the quality of patient care.
Competing interests:
No competing interests
28 March 2019
Antonio Sanchez Vazquez
Research Fellow
Anglia Ruskin University
Anglia Ruskin University, East Road, Cambridge CB1 1PT
It’s easy to agree that in assessing quality of care we need to define and measure outcomes that matter to patients. This applies equally to the positive intended outcomes and the less predictable unintended outcomes.
By limiting balancing analysis to data which already exists, we run the risk of overlooking the unintended impact on patients from system change.
In essence, balancing measures should be balanced!
Competing interests:
No competing interests
26 February 2019
James D White
ST4 anaesthesia
Mark Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Re: Using data for improvement
Shah indeed makes a good point in that we need to consider more than one perspective when attempting to understand what quality is, then look at ways in which we can measure it, and finally find ways to give those measures meaning, with a view to improving (the quality of) patient care. The 'how' to achieve this is indeed a challenging question, not least because, we need to agree not only on what we need to measure, but more practically, what we actually are able to measure.
Quality is a concept that can be hard to define, especially in a healthcare context. While we may agree on what it is not, it is harder to agree on an objective definition of what it actually is, as well as how we can link available data to it. It is also important that we keep the focus on quality improvement, not on performance targets and accountability. The Donabedian model and its dimensions of care (structure, process and outcome) remain as insightful as when first proposed over 50 years ago (Donabedian Evaluating the quality of medical care. Milbank Memorial Fund Q. 1966; 44(3) (suppl):166‐206), and still remains a leading framework in respect of evaluating the quality of healthcare. However, while other conceptual models have also been developed, none have allowed us any closer to the main goal of understanding the factors that contribute to good quality healthcare services, and how we can affect them to improve quality of care.
Highlighting the importance of qualitative data as the source of patient inclusion to identify factors that they see as contributing to better quality care is vital if we are to join up the ‘what we need to measure’, with the ‘what we are actually measuring’. If we are to move towards giving patients more of a voice in improving the quality of their care, this can only be achieved via in-depth analysis based on qualitative data.
Indeed we are now seeing a renewed interest in the importance of qualitative data. Since Pope et al published in 2002 (Pope C, van Royen P, Baker R Qualitative methods in research on healthcare quality BMJ Quality & Safety 2002;11:148-152), not including the first month, the number of times per month their paper was accessed gravitated around 20-60 until March 2017, when it increased steadily to approximately 500 in February 2019 (https://qualitysafety.bmj.com/content/11/2/148.altmetrics).
To ensure that we really are getting to the themes necessary to generate evidence to answer the ‘how’ and’ why’ questions, needed to feedback and guide quality improvement, then we need training of healthcare practitioners to increase their knowledge and skills regarding selection of research design. Cross-disciplinary collaboration and inclusion of those with experience of qualitative health services research, should also lead to richer data, and should be encouraged (Williams V, Boylan A, Nunan D. Qualitative research as evidence: expanding the paradigm for evidence-based healthcare. BMJ Evidence-Based Medicine Published Online First: 08 March 2019. doi: 10.1136/bmjebm-2018-111131).
Finally, and maybe most importantly, findings must be acted on and the measurement for quality improvement practices become standard in the training of healthcare professionals and in the running of healthcare organisations. Otherwise we risk measuring for measuring’s sake, and not using the data for improvement in the quality of patient care.
Competing interests: No competing interests