مجلة موقع ووردبريس عربي آخر
The discussion on quality of care has come a long way: from the efforts and research of visionaries such as Ernest Codman and Avedis Donabedian in the 1970s to the introduction of quality management and continuous quality improvement; from assessing quality from the perspective of a single profession to a more integrated and process oriented view; from control to improvement. Most of this development has been driven by pioneers with an outstanding vision, such as Don Berwick, who felt that we could do better for our patients and must improve. However, numerous publications, countless conferences, and broad discussions have not yet produced sufficient improvements of actual quality. This week the journal Quality in Health Care adds to this debate with a supplement on Organisational Change: The Key to Quality Improvement that reviews current thinking (and achievements) in the NHS in particular and health care in general (see www.bmj.com or www.qualityhealthcare.com). It provides yet another sign that what has been achieved cannot yet satisfy patients, payers, and professionals. So why is it so hard to get real improvement and change?
Over the past century health care has also come a long way—from the doctor in a solo practice, a generalist able to master all the relevant medical knowledge and apply it to the treatment of his patients, to the network of highly specialised consultants, who depend on each other for complementary expertise; from the asylum, where the interaction of nurses and doctors could guarantee optimal treatment, to today’s hospital, where personnel clustered in over a thousand job categories have to run a highly complex and interactive system.1 As different as inpatient and outpatient settings are, both have one aspect in common: the mere size and complexity have made it impossible for any single individual to control and guide the operation, and no single profession can claim to be able to guarantee high quality care. As the British Nobel Prize winning economist Ronald Coase has taught us, organisations develop because, with increasing scope and size of an operation, transaction costs defined as the costs of obtaining additional resources and information, increase to a point where it is worth while creating formal organisations.2 Health care has, under increasing cost pressure, finally come to realise an important implication of Coase’s theory: if care is to be of higher quality and lower cost the key to improvement lies in better organisational structures and processes The Quality in Health Care supplement collects together a series of valuable papers that aim to help our understanding of what it means for health care to organise for high quality performance.
As Leatherman, Sutherland, and Buchan point out, much of the success of quality improvement efforts will depend on clarifying roles and responsibilities and on the availability of data, appropriate incentives, and performance indicators.3 4 One of their main lessons is that quality will improve only if healthcare systems demand and support it. However, this is, as other contributors emphasise, only part of the story. The other important part of the picture deals with the organisational performance of real health care. Studies and experience from numerous consulting projects indicate that there is much room for improvement.
Up to this point a student of management and organisation theory could only be stunned by how little the efforts to improve quality have learnt from current thinking in management theory and from the experience of other industries. In a groundbreaking study of quality departments in the air conditioning industry David Garvin found that those firms that use their quality departments to facilitate improvement by work teams do measurably better than those who rely on audit.5 Although these findings are not unique and are supported by theory, some health systems still rely on external control and audit. This lack of openness to the experience of others may in part be due to the belief of most doctors that health care is fundamentally different and has therefore little to learn from other disciplines
