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Quality Care Within NHS

Attree, M (2001) - A study of the criteria used by healthcare professionals managers and patients to represent and evaluate quality care.

Journal of nursing management (2) pp67-78

Wallace et al (2001) - Organisational strategies for changing clinical practice: how trust are meeting the challenges of clinical governance.

Quality in Health Care. (2) pp 76-82.

Both of these papers are essentially about the issues of quality within the NHS. The Attree paper sums up the difficulties involved in the actual measurement of the indices of quality with the observation that there are many differing perceptions and models of quality.

To some extent, quality is a reflection of the particular modality that is currently under consideration. The quality of management provision will require different criteria of assessment from the quality of the meals provided on the wards. This particular analogy serves to illustrate a further difficulty. One might be forgiven for thinking that the assessment of the quality of a meal might not present too much in the way of analysis, but the assessment of a management decision is fraught with far more difficulty, as there is invariably disagreement about the particular constraints that may be perceived to be relevant at the time. There may be constraints of money, time, availability or personnel, and all of these factors can impact on the decision made at the time. This dilemma is central to Attree's paper.

The Wallace paper is primarily about the management of change at the level of the NHS Trust. It examines in some detail the various management strategies that have been tried by some the various Trusts in England and whether the Trusts have either learned by their experiences or whether they have shared their experiences with other Trusts. It analyses their behaviour patterns and makes a number of recommendations as a result of its findings.

Both the papers, although essentially similar in their aspirations, are fundamentally very different in their approach to the problem, their methods of analysis, their ability to present their results coherently and above all, in their practical relevance to the NHS community as a whole.

Paper I. Attree, M (2001)

A study of the criteria used by healthcare professionals managers and patients to represent and evaluate quality care.

Journal of nursing management (2) pp67-78

Attree's paper is a complex one with a multitude of different themes running through it. It purports to examine the actual criteria that are used when different healthcare professionals and recipients of healthcare try to analyse the quality of care that the patient's receive.

The author begins with an overview of the difficulties involved in attempting to assess quality issues and a review of the significant literature on the subject. The main points to take from the review are that, almost without exception, the papers cited point to the fact that there are very few well constructed studies on the subject as many suffer from the difficulties outlined in the first paragraph of this essay and that is that there are many different criteria that can be applied to studies of quality.

The author appears to be fond of Donabedian (1986) as the author is quoted several times in this paper. One very relevant point, that is virtually seminal to the thrust of Attree's paper, is the point that Donabedian makes that quality was so diverse that neither a unifying construct, nor a single empirical measure could be developed and this was expanded by Buchan (et al 1990) with the observation that there is no single criterion which defines the quality of health services, in that quality is essentially a function of many variables. On the face of it, this would appear to make the task undertaken by Attree very difficult.

In attempting to rise to the challenge, Attree has devised a study, using the semi-structured interview technique, involving 77 subjects who were nurses, medics, managers, patients and their relatives. The paper does not indicate the nature of the underlying structure of the interviews and it would appear that the subjects were effectively asked to comment on any issues of quality that appeared important or relevant to them.

The structure of the paper is that it has been designed to look at three categories of criteria which were then subdivided and then subdivided again. This has lead to a very complex structure which makes it very difficult to extract any coherent theme. It is important to understand the overall layout of the paper, which does not actually become obvious until the 4^th and 5^th pages (pg.70 +71) are reached.

Each of the areas considered are fundamentally quite different, and therefore, in the wake of Donabedian and Buchan, we effectively have a different essay on each one of the themes. The author, wisely, has decided to include a discussion section after each of the major subcategories so that whatever has been distilled from that particular area of investigation is neither diluted nor lost in the overall discussion at the end. The structure adopted is depicted as:

A)    Care resources

i) Human

ii) Environmental Physical and Material

iii) Financial

B)    Processes

i) Nature of practice

a) Care functions and processes

b) Professional practices and standards

c) Methods of working

ii) Nature of the Practitioner

a) Human qualities

b) Interpersonal relationships

C) Care Outcome criteria

This is a very complex structure. The table on page 70 (table 2) also goes some way to help to give some sense of order to the results.

The overall impression that one gets from this paper is that it there is a structure to it, but the concepts involved are very nebulous. Table 2 underlines this statement with a delineation of the various responses from the various sub-groups. One slightly curious observation that is immediately apparent from this table is that, if one compares the results of the doctors and the managers (both are groups of seven), the doctors raise the topic of quality far more frequently than the managers do. On the face of it this is rather unusual, as one would hope that the managers would have quality as one of their targets. In the discussion on the point, the author cites the work of Idvall & Rooke (1998) and Ovretveit (1990) who define some aspects of Service Quality as being primarily dependent on the attributes of the actual service delivery system. The rather subtle difference (by inference) is that the criteria which actually relate to the context of the care being delivered tend to be construed by medical personnel as direct indicators of care quality, whereas managers tend consider it as being either prerequisites or antecedents of quality care. Cody & Squire (1998) amplify this viewpoint further by suggesting that in addition to this view it can be the absence of these same criteria that may be responsible for poor quality of care. In the study itself, the author comments on the fact that many participants agreed with this latter amplification of the point, as they actually frequently identified problems with the resource criteria in the terms suggested by Cody & Squire, specifying the lack of particular resources as being major factors in either the inability to deliver quality or factors which reduced quality.

The author expands this comment further by observing that the medical staff (both doctors and nurses), tended to quantify the inability to deliver good quality care (when it wasn't delivered), in terms of shortfalls of the optimum levels of staff, equipment or time - depending upon the actual modality being assessed, whereas the managers tended to assess the same situation in terms of being automatic, predictable and unrealistic expectations in the current era of economic control and constraint, suggesting that more effective use should be made of the currently existing resources (slight paraphrasing).

This difference highlights the basic problem with this paper. Although we applaud the concept of anybody attempting to analyse the concepts, terminologies, practicalities and opinions of many different specialities working within the NHS. It is the very fact that different disciplines have been demonstrated to have widely differing viewpoints, simply because their constraints and aspirations are wildly different, that makes this paper less useful than it might arguably have been. We would suggest that a better approach would have been to define separately the criteria used by the various disciplines and subgroups which have been approached here (viz. Nurses, Doctors, Managers, Patients and their relatives) and having defined their criteria, then analysed each separately. This would have been not only an easier exercise, as each sub-group would clearly have their own reasons and bias for holding the particular views that they do, and these could have been analysed, recorded and discussed. It would also have made the comparison easier. In its present form, the paper attempts to compare the criteria of the different groups directly without any direct analysis of their constraints.

We have used the doctor / manager comparison as an example to illustrate the point, but common sense would dictate that the same principles could equally well apply to a comparison between a nursing group and the group of patient's relatives.

This paper suffers from a lack of clear direction and viewpoint. The resulting discussion, although erudite and full of citations of other works to back up the points made, does not present clear findings that the reader can take away as the main thrust of the paper, without having to use considerable interpretation and inference.

To illustrate that point we can look specifically at the discussion section on page 76. This part of the paper seeks to discuss the findings on the issue of care outcome criteria. The first half of this section tells us nothing new and is nothing more than a rehearsal of what is already known on the subject. The middle section tells us that what has been found could have been predicted and is unsurprising (which is certainly true). The statement is then made the patients' focus upon their experiences of care as well as health outcomes is more unexpected, as the former criteria are not generally considered to be in the patient's primary interest, and thus are often absent from predetermined patient satisfaction questionnaire surveys. We would suggest that any experienced healthcare professional will tell you that this simply is not true. The only justification for this viewpoint is cited as the author's own previous work on the subject (Attree 1996).

If one analyses this point, it is not very good form to state a controversial point and then to cite only yourself as the only other justification for the view. Examination of the literature on the subject shows that this view is opposed by other writers such as Benner & Wrubel (1989), Fagerstrom (et al 1998) and more recently Parke & Brand (2004), none of whom are mentioned in this context.

To continue this critique of this particular section, one can point to the next section where the author cites various quotes from the various groups as examples. This is particularly muddled as, bearing in mind that this particular section is a discussion of the methods of working, the three comments cited would actually be better and more relevantly discussed in other sections of the paper.

Viz.

1) Nursing staff are quoted as mentioning specific problems due to low staff-patient ratios which surely is an issue of professional standards and human care resources.

2) Lack of continuity of contact with the patient is cited by many subgroups as a cause of low quality, which surely is an issue that should be under the section of interpersonal relationships.

3) The third point is that patients did not mention work methods as such other than to comment that how busy the staff were, which we would suggest is actually a function of nature of practice - care function and processes.

It would not be fair to criticise the whole paper as rather muddled, as it is accepted that the issues here are very complex and inter-related. We would therefore argue that this fact alone makes it all the more important to present this type of analysis with as few variables as possible, rather than to design a paper that considers rich multi-layered responses by multiple groups of stakeholders, who have differing viewpoints, over a wide range of issues. This leaves the casual reader with a confused and unclear view of the points that the author is trying to put across.

Whether we agree with the points or not is irrelevant to this argument, as anyone is entitled to express their views and analysis of an issue. It is clearly helpful, however, if the author wants us to give those views consideration and validity, that they present them in a clear and unambiguous fashion. In our judgement, this is not the case here.

The final nail in the coffin comes from the author herself in the section on Limitations at the end of the piece. In essence, she concludes by saying that the study used a small non-representative sample to explore the issues of quality care who gave opinions that were not generalisable. The participant's descriptions of quality care and the author's own categorisation may have been influenced by other work in the area. There is no may have been about it. The author tells us on pg. 68 that she used work by Glaser & Strauss1967 and Strauss & Corbin 1990 to identify the key criteria used.

In common with many pieces of research that produce inconclusive results. The author politely suggests that there is scope for further research on the subject.

This work is not without merit, as it does record the views of a small, (although probably unrepresentative and therefore ungeneralisable) cohort of stakeholders in one small part of the NHS.

However, it is verbose and confused in places, it relies heavily on citations of other literature to give it the semblance of credibility and, as we have demonstrated, it makes controversial claims which are only backed up by the author's own previously published works with no mention of the literature which supports the opposing view. One therefore cannot state that it presents an unbiased view.

We would have to conclude that the title of the piece A study of the criteria used by healthcare professionals managers and patients to represent and evaluate quality care. - although strictly accurate - is misleading, as the implication is that it is a representative study of a large cross section of healthcare professionals, managers and patients when, in reality, it is the recording and analysis of the semi structured interviews of a small unrepresentative cohort of NHS workers and some patients and their relatives.

Paper II. Wallace et al (2001)

Organisational strategies for changing clinical practice: how trust are meeting the challenges of clinical governance.

Quality in Health Care. (2) pp 76-82.

This paper has both similarities and differences from the previously discussed Attree paper. It sets out as its stated goal an examination of the Organisational strategies for changing clinical practice: how trust are meeting the challenges of clinical governance. The immediate similarity is therefore striking. A huge potential area of exploration and study in a similar field of delivering aspects of quality.

The size of the project appears to be daunting with a cohort that includes all of the NHS trusts across the South West and West Midlands regions (nearly one quarter of the NHS). The task was to analyse all of the strategies that the Trusts used for managing change, and also how they learned from their current and past experiences and translated this knowledge into future plans to manage further change.

The difference is however immediately apparent as soon as one starts to read and analyse the paper. The approach taken by Wallace (et al) is to simplify the question into an easily managed concepts with minimal variables, so that comparisons and analysis can be made more easily and more meaningfully. This effectively represents the other end of the spectrum from the Attree paper.

The Abstract and outline give a clear and well defined overview of the project with the précis of the results and brief conclusion setting out clearly the achievements of the project. The language is simple, clear and unambiguous. It is logically set out and therefore easy to read.

In broad terms, the paper breaks down the possible strategies that could (and have been) used for the implementation and management of change, into 13 different strategy types (Nickols.F 2004). Rather than the semi-structured interview (as Attree), Wallace and his colleagues chose either a closed Yes/No interview technique to elicit information, or the 4 stage Likert-type option responses. This has the effect of immediately rendering the information collected, easily amenable to statistical analysis. (Marek 1989)

The main findings in this study were that the most popular mechanisms for instigating and managing change proved to be Educational programmes and the adoption and introduction of protocols and guidelines.. Surprisingly, the least popular method was the use of performance incentives such as financial incentives, which is rather against the conventional wisdom of management change strategies found in industry. (Chaix-Courturier et al 2000)

The authors found that the strategies that were most frequently found to be the most effective, were those methods that employed facilitative methods, particularly those that promoted and facilitated best practice policies in clinical matters. This was contrasted with the methods that were found to be the least effective and these were the education based systems. Thus it appears that it was the experience of the Trusts that the most popular methods used to facilitate change management actually proved to be amongst the least effective.

The authors found that each Trust had its own ideas when it came to management of change, and the single most important predictor of which strategies were going to be employed was the previous history of the use of the same factor in the past. For example, the Trusts that tended to use the education strategy in the past, were the most likely to use that strategy again, even though there was evidence to show that it was amongst the least effective.

The paper also identified barriers to the effective management of change, and these included the lack of resources which were quantified as primarily money and time. This is at odds with the common theories which suggest that manpower is often the limiting factor (in industry) (Garside 1998)

The paper concludes with clear recommendations which are based on its findings, and these are that the Trusts have historically based their management of change strategies on their own experiences of the strategies that they have used in the past. This is sometimes in direct contrast to the evidence that has been available locally that the particular strategy may not have been the most effective for the particular job in hand. Curiously, despite this finding, most Trusts are optimistic in their predictions of their ability to achieve a positive impact on patient outcomes with the particular strategy that they have chosen to adopt.

The authors suggest that the Trusts should be more critical of their own policies and also look outside their own areas to see what lessons can be learned from the experiences of other Trusts who have been in similar circumstances.

The paper offers some critical advice to those Trusts who are still using low-efficiency methods of change management despite the presence of evidence which suggests that there may be more effective methods available.

The paper sets out its hypothesis and rationale in the first few paragraphs so that the thrust of the paper is immediately apparent to the reader. It follows this up with a paragraph on the purposes of the study and another on the methods that it proposes to adopt in order to achieve those objectives. In contrast to the Attree paper, it actually records the questions and protocol that the study used ( in an abridged form) so that the reader can assess the nature and depth of the enquiries that were made.

It is of distinct practical relevance that the authors included sections on suggested future use of strategies and also the barriers that it was able to identify to the development of clinical governance. It is of considerable importance for Trusts to be aware of some of the findings - for example - one of the major barriers to implementing clinical governance is the presence or absence of resources rather than the cultural issues that some other sources have suggested may well be relevant (Davies et al 2000)..

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To sum up

This paper is clear, concise, well constructed and of direct relevance to the future efficient running of the NHS. It is to be commended for its clear and unambiguous use of the English Language. It is fundamentally different in structure from the Attree paper, which is of marginal relevance to clinical practice in the NHS, badly written, far for clear in its outline, structure or purpose. The study of these two papers is a valuable object lesson in the structure and writing up of a complex research project. There are a great many valuable lessons to be learned from reading them both.

References

Attree 1996 Towards a conceptual model of quality care International Journal of Nursing Studies, 33, 13-28

Benner P & Wrubel J 1989 The primacy of caring. In Stress and Coping with Health and Illness Menlo Park CA: Addison - Wesley

Buchan H. Grey M. & Hill A. 1990 Score on Quality Health Service Journal, 8, 362-3

Chaise-Corturier C, Durand-Zaleski I, Jolly D, et al. 2000 Effects of financial incentives on medical practice: Results from a systematic review of the literature and methodological issues Int. J Quality in Health Care 2000. 12:133-42

Cody A. & Squire A. 1998 Nurses perception of good nursing care Professional Nurse, 13, 578-82

Davies TO, Nutley S, Mannion R, 2000 Organisational culture and Health Care Quality Quality in Health Care 2000, 9, 111-9

Donabedian A. 1986 Criteria and standards for Quality assessment and monitoring Quality review Bulletin, 12, 99-108

Fagerstrom L, Erikson K & Engeberg I. 1998 The patients perceived caring needs as a message of suffering Journal of Advanced Nursing, 28, 978-87

Garside P. 1998 Organisational context for quality: lessons from the fields of organisational development and change management Quality in Health Care 1998;7:8-15

Idvall E. & Rooke L 1998 Important aspects of nursing care in wards as expressed by Nurses Journal of Clinical Nursing, 7, 512 - 20

Marek K. 1989 The measurement of Patient Outcomes Journal of Nursing Quality Assurance, 4, 1-9

Nickols.F 2004 Change Management 101: A Primer Oxford University Press 2004

Ovretveit J. 1990 What is quality in the Health Services? Health Services Management, 86.132-3

Parke & Brand Ideas in Leadership Nursing Leadership Vol.17, No.1, 2004

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