9 minute read
The need for a global clinical standard
Defining quality is not easy and there is not always consensus on what good quality means, says Alf Theodorou, CEO and Founder of NewCourse
The on-going pandemic has been an incredible challenge for all of us, none more so than those involved in healthcare delivery across the world. In all corners of the globe, people took note of the extraordinary e orts of those working to provide care to our sick and needy, standing in unison to show their support for the new heroes of our generation. The pandemic also brought into sharp focus key elements of healthcare delivery, from the role of technology and attitudes to whether bricks and mortar hospitals are the right places to receive care; to the importance of leadership, the human workforce and the stark inequalities in funding, resources and capacity that exist. We have also seen rapid innovation, the like of which we might not have seen for many years to come, with young and old, clinical and non-clinical embracing technology; and a seismic shi in attitudes to our expectations of care and the importance of healthcare to us.
What do we mean by good quality care?
Perhaps the best place to start is to say that we all want to be able to access high quality care - that is, care that is most likely to result in the outcome we want. Defining quality is not easy and there is not always consensus on what good quality means. If you ask a clinician you will get a di erent answer to a patient, and again asking a friend or relative of those needing care and your answer might change again. Across the world’s economies and healthcare systems you will also see variation in definition. It is a question that needs answering. Healthcare organisations, regulators, governments and accreditation agencies have all defined quality either on a national or international basis.
There are plenty of league tables that rank hospitals, and their criteria as well as defined healthcare standards – such as the Care Quality Commission in the UK – are easily available. Good quality can mean that other clinicians would recommend a hospital; it can mean an excellent patient experience with hotel-like infrastructure and waterfalls in reception. Good can mean that care is evidence-based or that the results of treatment are positive. The definition, like the delivery of healthcare, is subject to huge variation. And we have not tried to measure anything yet.
Why is it important to think about what good looks like?
Healthcare consumption – if I can use that expression – has changed forever. From a patient perspective we are much more aware of our expectations from our healthcare provider and much more informed about our options for care. As measures of quality from patient experience to clinical outcome become more readily available, we will want to compare and contrast our options more than ever. Globalisation – despite the restrictions of the pandemic – has seen significant movement of people both for work and pleasure. The result is that we are o en accessing healthcare in a country we were not born in and so we inadvertently begin the internal process of benchmarking against what we know.
Health funders and payers are ever more conscious about the need to achieve value
through ensuring the right care is delivered at the right time and with the right outcome. Reducing variation and ensuring that care delivery is evidence-based allows them to keep costs down and strive towards accessible and a ordable care.
We are more conscious of the inequalities in access and quality across the world’s economies than ever before. From a healthcare provider perspective, hospitals across the world are committed to delivering high quality care and in most cases strive to get better. For many that means understanding performance, reducing variation in practice, learning and understanding what good looks like and working to improve. If we want to improve, defining the right standard is the starting point. This allows us to benchmark care and plan for improvement. It was Taiichi Ohno, the founder of Toyota’s Production System who said; “without standards, there can be no improvement.”
How do we measure quality or set standards?
Local or international regulators - from the aforementioned CQC to companies like Joint Commission International (JCI) or Accreditation Canada - spend a huge amount of intellectual resource and experience defining standards. In many respects there is huge consistency amongst regulators. We see increasing reference to global healthcare delivery priorities from safe surgery and the correct identification of the patient, to hand hygiene or infection control processes and informed consent. It is perhaps fair to say that we have a good idea about what appropriate governance and patient safety look like. At the same time, regardless of the presence of strong local regulation, the appetite for healthcare providers across the world to engage in international accreditation programmes has moved the conversation about clinical governance, risk management and patient safety forward a huge amount in the last couple of decades. The criticism of many of these systems, however, is that they are heavily process driven, focusing on the production of policy rather than good outcomes. Of course, a hospital that has the right infrastructure in place and is committed to, or required to, comply with standards will have many of the building blocks in place that will likely lead to better care. However, we know huge variation exists between healthcare providers who have achieved any of these recognitions. We also know that having excellent governance processes in place will not tell us where a hospital’s expertise or clinical focus areas lie. In essence, it can be an indication of good quality or good attitude but for those involved in making decisions about where to access care, it would not identify, on its own, the most appropriate cancer hospital or the best place to have a baby. Accreditation systems, especially on an international level, tend not to focus enough on clinical data – be it contextual data, volume or outcome – to allow benchmarking or understanding of clinical capability. And for healthcare users, that is a significant gap.
How do we measure effectiveness?
To measure e ectiveness requires clarity on what we are trying to answer. The move towards a more data-driven standard might seem an obvious step, but it is not one that cannot be taken without careful consideration. While good data might remove unnecessary subjectivity, we must consider the reliability of the data and that the metrics are fit for purpose, cautioning against over-, or mis-interpretation. One of the significant benefits of the right data model is that the measurement of improvement, definition of better and clearly articulated targets are easier than policy driven systems. Without measures of patient outcome it is really hard to get a measure of quality or to ensure we are talking the same language.
Many regulators and accreditors use a combination of self-assessment (audit), evidence review and onsite inspection. High variation o en occurs between documented process and reality and so clinical review remains a key component of appropriate assessment, regardless of the quality of the data collected. The best measure though is likely to be a combination of policy, infrastructure, outcome and patient experience.
Who can do this?
Defining and measuring quality is an open market. International accreditation has been dominated by the US, Canada and Australia and there is an argument that developed healthcare markets such as these have significant experience to share. The UK health system has ventured globally in pockets of activity and the NHS remains one of the best examples of a free-at-thepoint of access healthcare system that is driven by the same purpose and founding principles that saw it established. It is also worth noting the body of work completed in the UK that looked at separate standards and measures at a service line level that would add significant value to the definition of quality at a global level.
We can also see examples of incredible innovation in developing healthcare markets that o er opportunities for more established health economies to learn from. Whoever it is that decides to look at clinical specialty level standards will need to be able to contextualise healthcare delivery in diverse cultures and challenging health economies. It will involve the collaboration of a cross section of professionals, including patients, and should be driven by a desire to understand what good outcome looks like, robustly measured and focused on driving improvement.
Alf Theodorou CEO NewCourse
The challenge of developing clinical standards
Once there is clarity on what we want to measure, the individual clinical standards and metrics will start to take shape. The process of defining and agreeing standards is not an easy one. Consensus might take time and we might have to accept a more iterative development process, especially as we look to define thresholds.
What is certain is that multiple perspectives from patients, clinicians, managers and regulators will be vital. The drive to understand what excellent care looks like for an individual specialty should build o the positive work that has been done over the last years to understand the pillars of good governance and patient safety. Objective measures of quality will need to respect local custom and regulation, not conflict with them. An awareness that perspective and culture might not only challenge our pre-conceived notions of ‘best’ but also that readiness to discuss
Alf Theodorou CEO NewCourse
certain topics is not the same the world over. Whether it is the stigma of mental health, attitudes to pregnancy or legislation about guardianship, a global healthcare standard needs to be cognisant of all of these elements. The challenges of good quality, reliable and robust data will need to be looked out as we know that the information we get out of a system is only as good as the information put in.
We also need to be realistic that variation in healthcare exists and that not all healthcare systems are currently at the same starting point. Most accreditation systems set a standard that everyone needs to achieve in order to earn their badge. One benefit of driving to improve the outcomes of care could be the opportunity to recognise where providers are on their own improvement journey; recognising quality in context and creating a tiered solution that can inspire continuous improvement.
The rapid innovation and changes to healthcare delivery seen during this pandemic period have highlighted the need to be adaptable. Not just in what we measure but how we measure. The focus should be on consistency and fairness and creating a non-punitive environment that will drive continuous improvement and learning.
So do we really need to do it?
The delivery of healthcare cannot stand still. Healthcare organisations need to continually improve the care they provide and improvement starts with knowing how good you are. Accreditation systems and local regulation have played an important role in focusing minds on key topics of patient safety and clinical governance. However, there are significant gaps in our measurement of good quality care at a specialty level, certainly on a global perspective. A focus on this important area has the potential not only to improve our understanding of care but to make that objective and data driven. This will o er opportunities to learn, innovate and drive continuous improvement that will tackle the burden of rising healthcare cost and inequalities in care. Ultimately, being able to define clinical standards will improve outcomes for patients. And that is a worthwhile use of our time.
Contact Information
alf@newcourse-healthcare.com
