1. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector

2. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector The recipients of a service are not just: CONSUMERS of the service but also CITIZENS i.e. people can demand the right to certain services, backed up by legal authority and political/community pressure PUBLIC GOODS are provided for the whole community but ‘consumption’ seen in a different light

3. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Who is the CUSTOMER of local authority planning services ? the BUSINESS paying the fee for planning permission ? The ACTUAL CUSTOMERS of the business The FUTURE CUSTOMERS of the business The RESIDENTS affected by the planning proposal ?

4. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector ‘Auntie Nelly’ needs a hip operation : if Nellie is the CUSTOMER, then who is the PURCHASER ? Nellie herself (from her own resources) Nellie’s family (own resources) The local community (appeals for funds) Health insurance (BUPA,PPP) GP fundholder (now Primary Care Group) District Health Authority (in purchasing capacity) Specialist charities

5. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Who gets the resources: Child ‘B’ case http://www.oheschools.org/ohech1pg8.html The treatment available to one consumer has to be weighed against that of other potential consumers when resources are limited.

6. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Health Services share some of the more general characteristics of consumers of public services INPUTS(well-trained personnel, equipment) PROCESSES (protocols, treatments) OUTPUTS (completed CABG, for example) OUTCOMES (increased life expectancy, quality of life)

7. BS2914 Quality Management and Customer Care 1: What is Quality ? Where does ‘Quality’ come from [1] ? A concern with competitiveness from the emergence of the global economy Developments in ITC Dislocation of economies in the 1970s Concern in the 1980s in the Public Sector Economy, Efficiency, Effectiveness Value for Money

8. BS2914 Quality Management and Customer Care 1: What is Quality ? APPROACH TO QUALITY ROLE OF THE USER USER INVOLVEMENT MEASUREMENTS DEPLOYED UniversalPurchaserMinimalZero defects, SPC Service Distinctiveness ConsumerIndividualised interactive ‘Gap’ analysis Public SectorCitizenCollectivist Interactive Citizen’s Charter; League tables ‘Traditional’ healthcare ‘Passive’ patientAcquiescent co- production Audits, satisfaction surveys ‘Empowered’ healthcare ‘Active’ patientParticipative co- production Patient-oriented surveys

9. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Notice the distinction between TRADITIONAL healthcare (quality is PRODUCER DEFINED) ‘Empowered’ healthcare (quality is not only producer-defined but also consumer-evaluated) Distinctions can also be drawn between: Standards and Charters (‘Patient’s Charter’) Continuous Quality Improvement (USA experience)

10. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector DONABEDIAN – Classic formulation of quality Structure (buildings, staff, equipment) Process (all that is done to the patient) Outputs (immediate results of medical intervention) [Outcomes – gains in health status ] Each ‘end’ may be seen as the means to a further ‘end’ – so processes and outcomes are more interlinked (e.g. quality structures and quality processes are more likely to lead to quality outcomes)

11. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector DONABEDIAN – Later formulation of quality ‘the quality of technical care is defined not by what is done but by what is accomplished. Consumers are uniquely able to say what outcomes are to be pursued, what risks are to be accepted in return for what prospects of amelioration and at what cost’ What happened between late 1960’s (classic Donabedian) and the late 1990’s? (later…)

12. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector MAXWELL’s definition (1992): Effectiveness (achieve intended benefit) Acceptability (satisfies reasonable expectations) Efficiency (resources not over-supplied to some patients to the detriment of others) Access (those who need services receive them) Equity (Resources are fairly shared) Relevance (treatments are appropriate)

13. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Varieties of audit: Medical audit (by clinicians) Nursing (clinical) audit Multi-professional audit Consumer Audits (not well developed) Note also… League Tables Patient’s Charter initiative

14. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Joss and Kogan (‘Advancing Quality’) undertook a systematic evaluation of the implementation of TQM into 19 pilot sites in the NHS (using also 2 commercial comparators) No before/after evaluation Quality does not come ‘free’ Majority of citizens had little to do with TQM Senior clinicians would be involved in quality issues if.. ~ pre-planned with key professionals (medical director) ~ use of survey data from initial evaluation made clinicians more aware

15. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Joss and Kogan’s analysis of the problems: 1.TQM is just one more initiative, and therefore is not ‘TOTAL’ 2.Frequent changes of policy are manifest 3.There is a lack of investment finance 4.The multi-professional nature of TQM (particularly acute in the NHS with a multiplicity of high status, well-trained professionals with high professional ethos)

16. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Patient ‘empowerment’ Is ‘empowerment’ another contested concept? Empowerment often means empowerment for managers, not for front-line staff, patients Prime impetus behind this notion that most practices of patient satisfaction are flawed (‘happy sheets’) because of methodological sloppiness, inadequate sampling, tick-in-the- box questiionnaires (i.e. producer-led)

17. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Consumer-friendly approaches Consumers are consulted (interviews etc.) to ascertain those elements of the service to be measured Consumers engage in consumer audit (the application of qualitative research methods to find out what patients, carers and potential users think of health services and want from them)

18. BS2914 Quality Management & Customer Care 11: Quality Management in Health/Public Sector Ecological approaches to quality (M. Hart) Attempt to measure quality not solely by quantitative means but by capturing the meanings imputed to episodes Examine the trajectories of medical care (i.e. series of linked sequences in which each episode is linked to prior experiences) Gain perceptions of all of the social actors (patients, all clinical staff, all reception staff etc)