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Healthcare service quality: towards a broad definition
Healthcare service quality
Ali Mohammad Mosadeghrad School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran Abstract
203 Received 10 November 2010 Revised 28 March 2011 Accepted 30 May 2011
Purpose – The main purpose of this study is to define healthcare quality to encompass healthcare stakeholder needs and expectations because healthcare quality has varying definitions for clients, professionals, managers, policy makers and payers. Design/methodology/approach – This study represents an exploratory effort to understand healthcare quality in an Iranian context. In-depth individual and focus group interviews were conducted with key healthcare stakeholders. Findings – Quality healthcare is defined as “consistently delighting the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patient’s needs and satisfies providers”. Healthcare quality definitions common to all stakeholders involve offering effective care that contributes to the patient well-being and satisfaction. Practical implications – This study helps us to understand quality healthcare, highlighting its complex nature, which has direct implications for healthcare providers who are encouraged to regularly monitor healthcare quality using the attributes identified in this study. Accordingly, they can initiate continuous quality improvement programmes to maintain high patient-satisfaction levels. Originality/value – This is the first time a comprehensive healthcare quality definition has been developed using various healthcare stakeholder perceptions and expectations. Keywords Healthcare organizations, Quality, Definition, Pluralistic evaluation, Iran, Health care, Customer services quality Paper type Research paper
Introduction Quality has become an increasingly predominant part of our lives. People are constantly looking for quality products and services. This desire for quality has caused company managers throughout the world to consider quality as a strategic goal to achieve competitive advantage. If product or service quality improves, costs decrease, productivity increases and a better products or services are available for clients, which in turn enhance organisational performance and provide long-term working relationships for employees and suppliers. The word “quality” is derived from the Latin “qualis”, meaning “what kind of” (Glare, 1983). The Merriam-Webster Dictionary (2010) defines quality as “The degree of excellence; superiority of kind; and a distinguishing attribute”. Quality, because of its subjective nature and intangible characteristics, is difficult to define. It is an elusive and abstract concept, which has many meanings and interpretations (Seawright and Young, 1996). Definitions vary depending on whose perspective is taken and within which context it is considered. Quality, therefore, has been defined as “value” (Feigenbaum, 1951); “excellence” (Peters and Waterman, 1982); “conformance to specifications”
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(Gilmore, 1974); “conformance to requirements” (Crosby, 1992); “fitness for use” (Juran, 1988); and “meeting and/or exceeding customers’ expectations” (Parasuraman et al., 1985). Deming (1982, p. 176) defined quality as “producing products with a predictable degree of uniformity and dependability at low costs and suited to the market.” Feigenbaum (1991, p. 7) defined the term as “The total composite product and service characteristics of marketing, engineering, manufacturing and maintenance through which the product and service in use will meet the expectations of the customer.” Flood (1993, p. 226) argues that quality is “meeting customers’ (agreed) requirements, formal and informal, at the lowest cost, first time and every time”. Health service quality is even more difficult to define and measure. Distinct healthcare characteristics such as intangibility, heterogeneity and simultaneity make it difficult to define and measure quality (Joss and Kogan, 1995; Ladhari, 2009; McLaughlin and Kaluzny, 2006; Naveh and Stern, 2005). Healthcare’s complex nature, its many participants with different interests in the healthcare delivery and ethical considerations add to the difficulty (Eiriz and Figueiredo, 2005; Rohlin et al., 2002; Zabada et al., 1998). Different stakeholders have different perspectives, interests and definitions. Therefore, healthcare quality requires a multi-dimensional definition that encompasses various healthcare stakeholder needs and expectations. Literature review Healthcare service is an intangible product and cannot physically be touched, felt, viewed, counted or measured like manufactured goods. Producing tangible goods allows quantitative measures, since they can be sampled and tested for quality throughout the production process and in later use. However, healthcare service quality, because of its intangibility, depends on service process, customer and service provider interactions (Joss and Kogan, 1995; McLaughlin and Kaluzny, 2006; Naveh and Stern, 2005). Some healthcare service quality dimensions, such as consistency, completeness and effectiveness are hard to measure beyond the customer’s subjective assessment. It is often difficult to reproduce consistent healthcare services, which differ between producers, customers, places and time. This “heterogeneity” can occur because different professionals (e.g. physicians, nurses, etc.) deliver the service to patients with varying needs. Quality standards are more difficult to establish in service operations. Healthcare professionals provide services differently because factors vary, such as education/training, experience, individual abilities and personalities ( Joss and Kogan, 1995; Jun et al., 1998; McLaughlin and Kaluzny, 2006). Healthcare services are simultaneously produced and consumed and cannot be stored for later consumption. This makes quality control difficult because the customer cannot judge “quality” prior to purchase and consumption. Unlike manufactured goods, it is less likely to have a final quality check. Therefore, healthcare outcomes cannot be guaranteed. Donabedian (1980, p. 5) defined healthcare quality as “the application of medical science and technology in a manner that maximises its benefit to health without correspondingly increasing the risk”. He distinguishes three components: technical quality – the effectiveness of care in producing achievable health gain; interpersonal quality – accommodating patient needs and preferences; and amenities – such as physical surroundings and organisation attributes. Øvretveit (1992, p. 4) defines quality care as the “Provision of care that exceeds patient expectations and achieves
the highest possible clinical outcomes with the resources available”. He developed a system for improving healthcare quality based on three dimensions: professional; client and management quality. Professional quality is based on their views of whether professionally assessed consumer needs have been met using correct techniques and procedures. Client quality is whether or not direct beneficiaries feel they get what they want from the services. Management quality is ensuring that services are delivered in a resource-efficient way. According to Schuster et al. (1998), p. 518), good healthcare quality means “providing patients with appropriate services in a technically competent manner, with good communication, shared decision making and cultural sensitivity”. These healthcare services must meet professional standards. On the other hand, they believe that poor quality means too much care (e.g. providing unnecessary tests and medications with associated risks and side effects), too little care (e.g. not providing an indicated diagnostic test or a lifesaving surgical procedure), or the wrong care (e.g. prescribing medicines that should not be given together). Leebov et al. (2003), p.4) believe that quality healthcare is the right and ethical thing. They argue that healthcare quality means “doing the right things right and making continuous improvements, obtaining the best possible clinical outcome, satisfying all customers, retaining talented staff and maintaining sound financial performance”. For Lohr (1991, p. 21), quality healthcare is “the degree to which healthcare services for individuals and population increases the likelihood of desired health outcomes and is consistent with the current professional knowledge”. Accordingly, the quality healthcare service goal is to increase the likelihood of achieving desired health outcomes for the patient. This definition also emphasises the importance of applying professional knowledge when providing healthcare services. Joss and Kogan (1995), in their model, see quality in three dimensions: technical; systemic; and generic. Technical quality is concerned with the professional work-content within a given area. Systemic quality refers to system and process quality that operate across the boundaries between work areas. Generic quality refers quality aspects that involve inter-personal relationships. Gronroos (1984) distinguished two types of service quality: technical and functional. Technical quality refers to delivering core services or their outcomes (i.e. what is offered and received), while functional quality refers to the healthcare service delivery process or the way in which the customer receives the service (i.e. how the service is offered and received). Patients usually rely on functional quality (facilities, cleanliness, food and provider attitudes) rather than technical quality when evaluating healthcare service quality (Wan Rashid and Jusoff, 2009). Health service quality definitions indicated in the literature can be placed into two groups: (1) Healthcare services whose characteristics and features meet predetermined specifications and standards. In this approach, quality is defined as “conformance to specifications, requirements or standards” and “satisfying provider’s expectations”. The focus is internal (i.e. supply-side quality). Terms such as accuracy, reliability and efficacy compose quality in this category. (2) Healthcare services whose characteristics and features meet or exceed customer needs and expectations. In this approach, “quality” is defined as “satisfying customer expectations and needs”. Hence, the focus is external (i.e. demand-side quality). Terms such as effectiveness, empathy, safety and affordability are quality attributes in this category.
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Patients’ healthcare service-quality perceptions influence their choice of a healthcare setting or recommending it to family or friends. Therefore, healthcare managers and practitioners should implement continuous quality improvement programmes to maintain high patient-satisfaction levels. However, healthcare services cannot be improved unless they are accurately defined and measured. Healthcare delivery is shaped by clients, providers, regulators, payers and suppliers. Healthcare stakeholder perspectives and priorities must be considered in any effort to define, measure and improve healthcare quality. While empirical research has been carried out in this area (e.g. Conley et al., 2003; Hudelson et al., 2008; Muntlin et al., 2006; Radwin, 2000), little has been conducted into Iranian healthcare service quality (Tafreshi et al., 2007). Most studies were limited to one or at the most two healthcare stakeholder perspectives. Aims This study, therefore, aims to fill this research gap by empirically exploring healthcare professional, client, manager, payer, policy maker and accreditation staff’s service-quality perspectives in Iranian healthcare organisations. The findings should encourage healthcare providers to regularly monitor healthcare quality using identified quality attributes and initiate continuous quality improvement programmes considering various healthcare stakeholders concerns and priorities to maintain patient satisfaction. Method Healthcare’s complexity and multi-dimensionality means that research exploring healthcare quality is methodologically difficult. There are many participants involved in healthcare delivery, each having their own interests and concerns (Hassan, 2005). Therefore, quality assessment cannot be carried out reliably by one stakeholder (patient or provider) alone. Pluralistic evaluation (Smith and Cantley, 1985) can overcome professionally dominated healthcare evaluation traditions by identifying and representing stakeholder group views, including the marginalised so that objective findings are developed. The pluralistic approach does not rely on consensus but evaluates multiple perspectives. Hence, each stakeholder group has their views and concerns represented in the evaluation (Hall, 2004; Hart, 1999). Individual and focus group interviews were conducted with key healthcare stakeholders in Isfahan, Iran. These included 384 clients, 266 providers, ten each of managers, policy makers, payers, suppliers and accreditation panel members. Participants were asked about healthcare quality definitions and high-quality healthcare service attributes. Settings and participants The sampling strategy had to include multi-professional healthcare organisations dealing with many stakeholders. A purposive (Maxwell, 2004) sample (nine stakeholders groups) representing the larger population was employed to adequately capture the population’s heterogeneity (see Table I), which gives the greatest scope for expressing different viewpoints while comprehensively describing the study phenomenon (Polit and Beck, 2003). Isfahan medical university is responsible for planning, providing, evaluating and accrediting healthcare services in Isfahan province. Hospital care is provided by regional hospital networks located in the main cities; including government financed Ministry of Health (MOH), Social Security
Groups
Participants and codes
32 Focus group discussions with in-patients (IPG) 64 Individual interviews with outpatients (OP) Patients’ relatives 64 Individual interviews with patients’ relatives (RE) Providers 64 Individual interviews with physicians (MD) 24 Focus group discussions with other providers (PRG) Managers Ten individual interviews with managers (MA) Policy makers Ten individual interviews with policy makers (PM) Suppliers Ten individual interviews with suppliers (SU) Payers Ten individual interviews with payers (PA) Accreditation staff Ten individual interviews with accreditation staff (AC) Quality managers Ten individual interviews with quality managers (QM) Total
Number
Healthcare service quality
Patients
320 64 256 10 10 10 10 10 10 700
Organisation affiliated (SSO) and private hospitals. The study was carried out in eight hospitals, four MOH (three teaching), two SSO and two private hospitals to represent Iran’s three dominant hospital care systems. In-depth, face-to-face interviews were used for gathering outpatient, inpatient, relatives, doctors, managers, policy makers, accreditation staff, suppliers, payers and quality managers’ perspectives. The study also relied on focus groups to generate qualitative data on inpatient and provider preferences (except doctors) for healthcare quality. In each hospital, four focus group meetings were conducted with inpatients with more than two days inpatient experience. 32 focus groups were conducted with 256 inpatients (eight inpatients in each group), stratified to be homogenous, based on gender. Moreover, a purposive sample of eight outpatients in each hospital was invited to participate in in-depth individual interviews (n ¼ 64). Inclusion criteria were: Persian speaking; 15 years or older; not suffering from severe mental or cognitive disorders; willing to participate; and communicable. In each hospital, three focus group meetings were held with employees from nursing, paramedical and support departments who volunteered to participate. Each group included eight participants (n ¼ 192). It was difficult to gather physicians into focus groups owing to their busy schedules. Thus, it was decided to use in depth face-to-face interviews (eight in each hospital, n ¼ 64). A purposive sample of eight family members in each hospital was invited to participate (n ¼ 64). Ten in-depth face-to-face interviews each were held with other stakeholders including policy makers, payers, suppliers, managers, quality managers and accreditation staff (n ¼ 60). Potential participants were approached individually by the researcher, informed about the study aims and methods and invited to participate in the interview after informed consent was obtained. The researcher created a relaxed atmosphere and encouraged free discussion. Data collection In-patients interviews were conducted by the researcher in private rooms off the main ward. Interviews with outpatients were conducted in the outpatient department after they received services. Interviews with other healthcare stakeholders were conducted in their office or in a seminar room as focus groups. The interviews were recorded digitally with the participants’ permission to facilitate analysis.
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Table I. Interviews and codes
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Data analysis Digital files were transcribed by the author. Content analysis was used to identify, label and categorise stakeholder quality perceptions. Each transcript was read while listening to the conversation to verify transcription accuracy. Confidentiality was assured and anonymity protected using alphabetical and numerical codes in all voice records and reports. Transcripts were reviewed several times to identify codes, categories and themes from the respondent’s words using QSR NVivo qualitative data-analysis software (version 7). Codes found to be conceptually similar or related in meaning were grouped into categories and reduced into major themes (Strauss and Corbin, 1998). Evaluating research quality After data analysis, member checks (respondent validation) were done in face-to-face discussions with a participant subgroup to verify and validate the findings. Member checking is reporting preliminary results to participant groups, asking for comments on findings and interpretations, and incorporating these critiques into the results. The researcher also used peer debriefing with five quality management experts. Peer reviewers were debriefed using summarised data, categories and themes that emerged, and the researcher’s interpretations. Debriefing provided the researcher with opportunities to clarify his interpretations and to examine his biases. The researcher meticulously described and documented all research phases including research setting and participant selection, data collection and data analysis with sufficient detail to allow judgements about research reliability and transferability. Results Table II shows interviewees’ demographic characteristics. 51 per cent (358) were male and the full sample’s average age was 38 years (range 15-78 years). The author used comparative analysis to identify responses from different participants in dissimilar healthcare settings. Four quality-healthcare meanings emerged. Some respondents interpreted it as “conformance to pre-determined guidelines and standards”. Some explained it primarily as “meeting customer needs and expectations”. Others understood it as “value” and “excellence”. Conformance to pre-determined standards and meeting customer needs were the prevailing definitions. Healthcare quality definitions common to all stakeholders involve offering effective care that contributes to patient well-being and satisfaction. Some people define healthcare quality as an abstract, “excellence” term – meaning a degree of perfection and highest standard. “Doing the job in the best way” (SU2); “desired [clinical] outcomes” (MD41); “the best of everything” (RE23); “good caring and facilities” (RE27); “providing the best possible services by the best providers” (IPG14); “providing the best caring and treatment to achieve the highest level of health status for patients”(PRG19) and “providing the optimum treatment and nursing care to patients” (PRG7). Quality simply can be people’s healthcare service perception of value. The value-based quality definition considers performance at an acceptable price: “I was admitted to Hospital ‘X’ . . . It is not worth the money I paid” (OP35); “I was charged 50,000 Rials [US$5] for the patient pack containing clothes, slippers, toothbrush, and toothpaste. It was not worth it.” (IPG2).
Demographic variables
IP
OP
RE MD PR MA PA PM SU QM AC
Gender Male Female
50 50
Marital status Single Married
21.4 10.9 17 78.6 89.1 83
Age Less than 20 20 to 29 30 to 39 40 to 49 50 þ
9.4 19.9 25.4 23.8 21.5
Education Illiterate Elementary Diploma Postgraduate diploma Bachelor of science Master of science General Practitioner (GP) Doctor of philosophy or medical consultant
48.4 45.3 78.1 35.8 51.6 54.7 21.9 64.2
90 100 100 50 10 – – 50
50 50
9.5 12.6 – – – – 10 90.5 87.4 100 100 100 100 90
10 90
3.1 – – 23.4 3.1 14.6 39.1 43.8 50.5 23.4 35.9 29.7 10.9 17.2 5.2
– – 30 40 30
– – 50 50 –
– – – – – 10 20 – 60 70 100 30 10 – –
– 10 50 40 –
12.5 3.1 1.6 – – 45.7 43.7 34.3 – 2.1 30.0 31.3 37.5 – 9.9 3.9 6.3 4.7 – 20.4 6.3 12.5 18.8 – 63.5 1.6 – 3.1 – 2.6 – – – 60.9 1
– – – – 40 10 20
– – – – 50 30 20
– – – – – 10 30
– – – – 40 – 10 – 40 50 – 40 – 10
– – – – 50 10 40
30
–
60
10
–
–
4.7 31.3 29.7 18.8 15.6
90 10
3.1
–
39.1
0.5
–
Notes: IP ¼ Inpatient; OP ¼ Outpatient; RE ¼ Relative; MD ¼ Medical doctor; PR ¼ Provider; MA ¼ Manager; PA ¼ Payer; PM ¼ Policy Maker; SU ¼ Supplier; QM ¼ Quality manager; AC ¼ Accreditation staff
Quality of conformance relates to the degree to which healthcare services meet certain standards or guidelines. Quality healthcare means striving for and reaching excellent healthcare-standards: “meeting a set of established standards” (QM2); “providing the caring according to predetermined standards” (PRG16); and “our caring should reach international caring-standards” (PR116). Quality healthcare also means meeting customer needs in a way that exceeds their expectations: “meeting patient’s physical and emotional needs” (PRG10); “meeting sensible customer expectations” (PRG7); and “meeting patient needs and expectations. Quality means patient satisfaction” (PRG22) When patients were asked to define quality, the most common responses were “getting the best result”, “getting cured from the illness” and “improved health status”. “For me quality means good results, good caring and good treatment” (IPG23); “I see quality in good results and improving my health status” (IPG29). They considered health services as high quality when services restored their health: “the total services that help me to regain my health as soon as possible” (IPG30). Quality also may be recognised by patients as prompt care, effective with error-free procedures: “quality is getting fast, appropriate and accurate diagnosis and treatment” (IPG18). Although patients are concerned with technical care, they mostly tend to form their opinions about service quality based on their assessment of non-clinical care such as availability
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Table II. The demographic characteristics of the participants
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of and accessibility to facilities and amenities, security in and around the facility, clean and comfortable rooms, privacy, tasty meals, comfortable clothes and a quiet and attractive environment. Healthcare services should be available to patients any time they need them: During my trip to Isfahan, I felt so bad and came to this hospital. The doctor said it is hepatitis and that I have to stay here [hospital] for about one month. I decided to go to my city. In Abadan [patient’s city], the doctor said “we do not have an ICU and in case there is a need, you must go to Ahvaz [another city]. I decided to come back to Isfahan” (IPG11).
Healthcare service availability is a necessity but it is not enough. Services should be accessible to clients if they are to be considered useful. Patients are concerned about having access to doctors and nurses (physical access) and having affordable (financial access) and acceptable healthcare services (conceptual access). Healthcare services should be physically accessible to clients: “although the doctor was competent, I am dissatisfied. One night my face was swollen. The nurse called him, but he did not turn up” (OP10). Affordability is a key access component especially when service costs are high and the patient has no insurance programme: “The medicines are very expensive. I cannot afford them” (IPG31). Healthcare services should also be acceptable and meet client wishes, desires and expectations. It has to be culturally sensitive: “I feel comfortable with a woman doctor. I feel more relaxed to talk to her about my disease” (OP19). “The doctor does not care about my religious beliefs” (IPG7). The healthcare service environment was acknowledged to be an important healthcare quality component. Clients preferred a clean and homelike environment. Cleanliness and hygiene considerations were mentioned by most clients as important quality attributes. Although a hospital is a place for treating diseases, there is always a chance of getting contaminated with infectious diseases. Contamination fears make clients worry during their hospital stay: “I have to come to the hospital for a blood transfusion regularly. I worry about the diseases that can be transmitted through blood” (OP57). “I am suffering from a kind of cancer. During chemotherapy, my body will be very weak and I can contract any disease quickly. I am so worried about this” (IPG29). Patients feel more comfortable if providers respect their privacy during counselling sessions and examinations. Lack of privacy can make it more difficult for patients to participate actively in their treatment plan: “although, she [doctor] was kind, it was difficult for me to explain my physical problem in front of all those [medical] students. I felt really embarrassed” (OP22). Patients desired technically knowledgeable, skilful, experienced and capable providers who can accurately diagnose and treat them effectively. Competent healthcare providers seemed to be an important quality indicator for clients: “the doctor is so important in order to have an accurate diagnosis and on time treatment” (IPG15); “some nurses do not know how to get my blood vein for injection; they hurt me” (IPG7). Tangible quality aspects such as pleasant environment and tasty food are also important: “the food is great. The breakfast was butter and honey. I could not eat it. Therefore, they gave me nuts and cheese” (IPG5); “the food is well packed. The room is well decorated. It is more beautiful than my own bedroom. It is coloured light pink – very beautiful” (IPG5); “I cannot leave the ward, because of my disease [cancer]. There is no entertainment or TV in the ward. I get depressed and want to go home” (IPG29).
Participants also defined quality as interaction between patients and providers. Many patients and their relatives rely on interpersonal relationships to evaluate healthcare quality because they lack sufficient technical knowledge. The interpersonal relations include active listening, trust, respect, confidentiality, courtesy, responsiveness and effective communication between providers and clients. Clients wanted providers not only to do their technical jobs but also to be caring, polite, courteous and friendly, to show respect, empathy, sensitivity and kindness and to express compassion and sympathy: A nurse just thinks that s/he has to get a blood sample. There is no good attitude here (IPG11); I wish they [providers] were more kind. I am their guest for a while. I will die soon because of my disease’s [cancer] progress. I would like to be treated with respect (IPG29).
Having supportive and caring staff responsive to individual needs was viewed as essential to providing quality hospital-care. Patients expect their caregivers to be more responsible and accountable and provide prompt service: I did not have medicine to take last night. However, the nurses came to see me regularly to make sure I was OK (IPG9); Last night I felt very bad. The nurses did not give me a painkiller. My daughter brought some for me from home (IPG1).
Patients expect healthcare services to be provided within an appropriate interval: “I did the X-Ray four days ago. However, I did not get the result yet to show it to the doctor. It makes the treatment process so long” (IPG4). “The nurse does not administer the medicines on time” (IPG24). Showing emotional support contributes to service quality. It was important for patients to get emotional support from providers to help reduce their vulnerability and anxiety: “I’m suffering from cancer. I do not know what is going on. I do not know whether I will be cured or not. I am completely disappointed. I need someone to talk to me and give me some support (IPG29). Nurses are great. They are like angels. They talk to me nicely. The first night I did not feel good, they came to my room every half hour. Their extreme kindness gives me tranquillity (IPG5). Patients expected staff to acknowledge and treat them as individuals, and interested in providing good quality care. Individualised care, which was related to patient need was viewed as good quality: “the doctor does not spend enough time with the patient. I said my belly is aching and he ordered [clinical] tests. It did not take more than a minute” (OP45); “the doctor does not bother himself to stand up and examine the patient’s throat. He just prescribes the medicine while sitting on the chair. At least he should see if the patient has fever or check the patient’s blood pressure” (IPG21). Patients were more interested in communication and information flow: “I think communication is an important factor, which helps me to trust in providers, ask my questions and feel free to talk about my [medical] problem” (IPG15). Communication includes listening carefully and attentively and providing clinical status and care-process information. Patients expect healthcare providers to tell them all the facts related to their treatment process, so that they can make an informed choice: “the nurse just told me “go and lie on bed No.11. She did not give me information about my disease and treatment process. The nurse did not tell me why the doctor prescribed these medicines for me” (IPG29). “At discharge, nobody told me when I should return to remove the stitches or for how long I would have to take the antibiotics” (IPG16). Patients expect doctors and nurses to clearly explain technical information in an understandable way: “I saw a physician explaining the treatment procedure to an old patient by using professional words. He
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[patient] does not understand it and will forget it. The physician should explain to the patient’s relatives” (PRG2); “I am from another city. Our culture and language are different. I may not understand their [caregivers] questions. They get angry if I ask them to repeat the question” (IPG12); “I did not understand what the doctor said. He just said something and left [the ward]. I do not know, whether he is going to do the surgery in this hospital or in another one. I have to ask the nurses” (RE20). Patient involvement in decisions about their care is another quality facet. Patients expect to be more actively engaged in treatment decisions: “the doctor does not let me ask my questions. Then, at home I think, if I had asked this question it would have been better” (IPG29). Patients are more likely to be involved when they are encouraged to be active: “a doctor should ask a patient questions about his/her age, income level, [medical] problem, diet, etc. A patient may not know what to say. When the doctor asks, the patient has to answer” (OP48). Care should cover all disease-management aspects – from prevention to rehabilitation. Patients also perceive a need for more comprehensive care, such as counselling and having access to scarce medicines: I am here [hospital] for my foot problem [broken leg]. Sometimes I feel no sensation in my hand. I asked a consultant to have a look at it. He gave me his business card and asked me to see him in his [private practice] office. I expect doctors to help me with my other problems as well (IPG15). The hospital does not provide some medicines that the doctor prescribed. I had to find them outside the hospital (IPG23).
Patients expected coordination between individuals and organisations involved in their care, such as multiple providers within a hospital, between doctors and other clinical staff across facilities and between their providers and their medical insurance plans: “the doctor asked for a laboratory test, but nobody [nurses] came to do the test; I had to go to the laboratory department with my daughter” (IPG30). Service reliability is another important healthcare-quality attribute. Clients expect providers to perform the promised services dependably and accurately: “This is the third time I am going to do this [clinical] test. The first time the test showed hyperthyroidism. The second time it showed hypothyroidism. Therefore, the doctor asked me to do it again but in this hospital” (OP6); “the opening time in the obstetrics clinic is 7.30 am. The time is now 8.00 am but nobody is there” (OP22). Relatives see quality as satisfying patient needs. They define quality as patient satisfaction: “Doing the job in the best possible way, which satisfies the patient” (RE57); “what satisfies people and meets their expectations” (RE17). They also describe quality in service-cost terms. Quality healthcare is one that meets client needs at a reasonable cost (value): “a private hospital is better than a public one. However, it is not worth the money that is paid” (RE3); “it [private hospital] is not worth that much” (RE11). Healthcare professionals tend to perceive quality in technical performance terms and the results of care. They consider healthcare quality to be “the right thing to do” according to “current technical standards” and “available resources” that satisfy “patients” and “them”: “quality is the degree to which a doctor reaches clinical results defined in the guidelines. The closer to the clinical standards, the higher the quality” (MD3); “doing the right thing right and doing it better than before every time” (MD4). While physicians emphasised clinical outcomes and clinical guidelines, nurses stressed
caring standards and meeting the patient’s needs: “providing excellent care according to nursing guidelines” (PRG7); “the way services are provided according to pre-determined guidelines and standards” (MD44). Administrative and support staff considered doing things right and customer satisfaction as good quality healthcare services: “meeting customer needs” (PRG6); “the right thing to do” (PRG6); “final satisfaction of the customer – both patient and employee” (PRG11); “doing the right thing right and doing it better next time” (QM10). When asked to define high-quality healthcare, managers emphasised both customer (internal and external) satisfaction and efficiency: “quality (keifieat in Persian) product or service means people enjoy (keif in Persian) using it. Services should satisfy both internal and external customers” (MA6); “quality means providing better services to patients and their relatives. These quality services promote patient health status” (MA2); “quality refers to meeting patient needs in a way that satisfies them and benefits the hospital as well” (MA8); “getting the maximum benefit by using the minimum resources” (MA8). Policy makers saw high-quality services as accessible, equitable and satisfactory to both customers and providers: “providing the right service at the right time with the lowest resource wastage, which satisfies both service provider and receiver. It involves easy access to rational, equitable and affordable healthcare services” (PM1); “quality means client satisfaction” (PM3). Third party payers defined healthcare quality in a patient satisfaction and healthcare cost context: “quality refers to providing cost-effective services that resolve customers” [healthcare] problems and make them happy with the services” (PA1); “quality means achieving customer satisfaction through providing effective services according to standards at the lowest possible cost” (PA7). Healthcare accreditation staff saw quality mainly as standards and customer satisfaction: “providing services according to standards” (AC8); “reaching care standards and providing the optimum services to patients” (AC3); “doing things right and doing it every time better than before. Overall, it [Quality] results in customer satisfaction” (AC1). Healthcare quality definitions vary according to the point-of-view and observer role, who may be a client, clinician, manager, policy maker or purchaser. Healthcare stakeholders defined quality using their profession’s language. An evaluation and accreditation panel member defined healthcare quality as: “right services according to the latest available standards” (AC4). A quality manager defined it as: “satisfying customers by providing the best services through continuously improving processes” (QM5). A pathologist explained quality as: “accuracy and reliability of clinical laboratory test results” (PRG8). Finally, quality was defined by a physician as: “accessible and affordable [healthcare] services, which promote patient health [status] and improve patient and provider satisfaction” (MD40) (see Table III). Patient satisfaction was considered an important service-quality indicator by different participants (patients, patients’ relatives, nurses, managers, policy makers and payers): “patient satisfaction is very important for us (MD11); “we do our best to satisfy patients” (MA1); “quality should involve customer satisfaction” (PRG3); “achieving patient satisfaction is our first goal” (PRG5); “quality means patient satisfaction” (PM3). However, professionals (e.g. physicians) mainly believed that patient satisfaction could not be considered a good healthcare-quality indicator, at least
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regarding technical service-aspects. Physicians argue that patients lack the clinical expertise to judge technical service quality: “our job is professional [technical] and the patient does not know many things about it. She/he does not know what is actually going on in the operation theatre” (PM1); “if I [consultant anaesthetist] use Halothane in the operation theatre instead of Isoflurane, the patient does not know the differences between them” (MD29); “it is defined in the medical profession that a neuroplasty surgery recovers 50 per cent of the nerve’s abilities. A patient might expect 100 per cent recovery and may not be satisfied. It is not possible technically” (MD43). Professionals believe that a patient can be satisfied with care that is not high quality and can be dissatisfied with quality care: It is difficult to define quality in healthcare. A patient might die even when high-quality services are provided; for example, a CVA [cerebro vascular accident] patient might die even when competent staff provided services using best equipment. On the other hand, a patient with a cold might recover, even if service quality was low (MD17).
Professionals considered clinical indicators as most important: “the final clinical outcome is important for me. Was the CPR [cardio pulmonary resuscitation] successful? Could I resuscitate the dying patient?” (MD2); “for me, the final accepted clinical outcome is important not patient satisfaction” (MD11). Managers, policy makers, payers and relatives considered cost-effectiveness as an important healthcare quality attribute. Clinicians, (particularly physicians) and patients did not recognise it as an important aspect of care in their definition. Descriptions of quality also depend on the healthcare setting. “Customer satisfaction” and “meeting patient’s requirements and expectations” were mentioned more by respondents in private hospitals. In contrast, “doing the right thing” and “meeting patient’s legitimate needs” were emphasised in public hospitals. Discussion Healthcare quality has varying definitions for clients, professionals, managers, policy makers, and payers. Different stakeholders have their own perspectives, interests and definitions of quality, based on the importance they place on different health-services elements. In this study, stakeholder perceptions of what constituted high-quality healthcare services were elicited. Eight quality Rights were identified in the service quality definitions provided by healthcare stakeholders: Right Care in the Right Way for the Right Individual in the Right Place at the Right Time by the Right Person and for the Right Price to achieve the Right Results. Right services refer to appropriate,
Table III. Healthcare stakeholder definitions
Group
Definition
Patients Relatives Providers Managers Policy makers Payers Accreditation staff Suppliers
Meeting needs and expectations Patient satisfaction and value The “right thing” to do according to “guidelines” and “patient satisfaction” Provider and client satisfaction and efficiency Patient and provider satisfaction Patient satisfaction and cost-effectiveness (value) Conformance to standards and customer satisfaction Doing the right thing
acceptable, necessary, accurate, safe, effective, comprehensive, patient-centred and excellent healthcare services. Right way relates to providing services efficiently using appropriate procedures. Right place means an accessible healthcare facility with available services. Right time means that services are provided when they are wanted or needed. Right provider refers to a competent, responsible, accountable, committed, supportive, kind, friendly and honest provider. Right individual means the service is provided to the right patient. Right price means the service is provided at a price that is reasonable to the provider and affordable for the customer. Right results refer to the best possible clinical outcomes. In other words, quality healthcare can be defined as: “Consistently delighting the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet patient needs and satisfies providers”. This definition integrates patient needs and technical healthcare service aspects – meaning that quality should always be based on changing customer expectations or functional requirements. In professional healthcare services, quality is a subjective, complex and multi-dimensional concept. The proposed definition is more comprehensive than other descriptions (Donabedian, 1980; Leebov et al., 2003; Lohr, 1991; Øvretveit, 1992; and Schuster et al., 1998). It provides a more comprehensive view of quality considering more quality-attributes ignored or less emphasised by other researchers. Generally, healthcare quality definition in this study include characteristics such as availability, accessibility, acceptability, appropriateness, affordability, competency, timeliness, privacy, confidentiality, empathy, attentiveness, caring, responsiveness, accountability, accuracy, reliability, comprehensiveness, continuity, equity, environment, amenities and facilities. Other attributes used to describe quality healthcare include providing education for the patient and family about patient health issues and including the patient and family in treatment planning processes. Efficacy, effectiveness, efficiency, ensuring safety and security, reducing mortality and morbidity, improving quality of life, patient health status and satisfaction have also been seen as quality attributes. Each stakeholder group emphasises different healthcare aspects, which does not mean that they are not concerned about other care-aspects. The interpretation common to all stakeholders, was customer satisfaction. Clients place significant emphasis on effective services, ready access to experienced and helpful providers, clean and safe environment and facilities, and amenities. For healthcare professionals, healthcare quality refers to service aspects that bring satisfaction to them – having the best possible outcomes (efficacious services) and meeting clinical guideline requirements. Their definition is close to the quality assurance approach, wherein quality is defined as adherence to care standards. Managers often emphasise client satisfaction and resource utilisation (efficiency), whereas payers considered customer satisfaction and cost-effectiveness as the most important indicators. Policy makers are concerned with equity, cost and clinical outcomes. Iran’s healthcare stakeholders defined healthcare quality as excellence, value, conformance to standards and meeting customer needs and expectations. Each quality definition has its own strengths and weaknesses: . Quality is excellence – it is most difficult to measure quality healthcare when defined as excellence (an elusive and abstract concept). Subjective attributes such as precision, perfection, flawlessness, reliability and safety make up the
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quality-composite in this category. These excellence attributes are likely to change over time. However, excellence-based definitions motivate healthcare providers to improve service quality. To achieve excellence, healthcare providers must strive for “zero defects” and “perfect” services. Quality is value – multiple healthcare-service attributes such as performance (effectiveness) and price are included in a value-based definition, which can be shown in the following equation: value ¼ satisfaction/cost. Quality defined as value can lead healthcare providers to improve efficiency. However, they may neglect service effectiveness. Hence, staff must concentrate on both effectiveness (conformance to specifications or meeting customer requirements) and efficiency to satisfy customers. Quality is conformance to standards and guidelines – this definition has an internal focus (i.e. supply-side quality). Healthcare organisations can monitor progress towards their quality goals objectively by measuring healthcare process or outcome against predetermined criteria and standards. Objective measures can be designed to assess healthcare service quality. Therefore, provider definitions influence the kind of care they offer. However, setting appropriate specifications and standards is a challenge for healthcare providers. It depends on providers’ ability to identify evidence-based standards based on patients’ needs and expectations. Quality is meeting customer needs and expectations – quality must ultimately be evaluated from the customer’s perspective (Reeves and Bednar, 1994). This definition has an external focus (i.e. demand-side quality). Defining quality as the degree to which healthcare services meet or exceed patient expectations allows practitioners to include more subjective quality-attributes (i.e. courtesy, kindness, helpfulness and equity), critical to customer judgments. Determining and measuring customer expectations is a complex task because often customers do not know what their expectations are. Instruments can be developed to measure the gap between customer perceptions and expectations.
Conclusion and implications A widely accepted healthcare-quality definition is required for its assessment and improvement. The author reported a pluralistic evaluation study to explore healthcare stakeholder quality perceptions. The evaluation revealed a comprehensive healthcare service quality picture in a way that would not have been possible had a singular evaluation approach been used. The pluralistic evaluation revealed that quality healthcare services have different meanings for clients, providers, managers, policy makers and payers. Those healthcare quality dimensions, important to every group involved in service provision, should be a priority for managers and practitioners. If they want to satisfy their clients then they need to perform well on these dimensions. The study adds to our healthcare-quality understanding and highlights its complex nature. Findings have direct implications for health service providers; they are encouraged to regularly monitor healthcare quality and initiate continuous quality improvement programmes to maintain or increase patient satisfaction. The findings have important
implications for policy makers. Their support, when providing resources and establishing supportive rules and regulations, is critical. This study helps to develop healthcare service-quality definitions. Qualitative methods explored healthcare stakeholder perspectives including patients, families, healthcare providers, third-party payers, managers, policy makers and accreditation staff. However, some research aspects limit the study’s robustness. The policy maker, manager and payer samples chosen for interviewing were small. A larger sample might have given different results. Respondents were Iranian healthcare stakeholders and the results cannot be generalised to other countries or healthcare systems. Future research can be conducted on how healthcare stakeholders in other countries, particularly in developed countries, define quality. Selection bias among participants may pose problems when drawing conclusions. The researcher selected the samples based on participants’ health service experience or knowledge (purposive sampling). Although samples represent populations, there was potential researcher subjectivity during selection. However, checking research findings with other representatives increased the study’s reliability. References Conley, H., Kubsch, S.M., Ladwig, J. and Torres, C. (2003), “Patients’ and nurses’, perceptions of quality nursing activities’”, British Journal of Nursing, Vol. 12 No. 19, pp. 1122-9. Crosby, P. (1992), Quality is Free, McGraw-Hill, New York, NY. Deming, W.E. (1982), Quality, Productivity, and Competitive Position, Cambridge University Press, Cambridge. Donabedian, A. (1980), The Definition of Quality and Approaches to its Assessment, Health Administration Press, Ann Arbor, MI. Eiriz, V. and Figueiredo, J.A. (2005), “Quality evaluation in healthcare services based on customer-provider relationships”, International Journal of Healthcare Quality Assurance, Vol. 18 No. 6, pp. 404-12. Feigenbaum, A.V. (1951), Quality Control: Principles, Practice, and Administration, McGraw-Hill, New York, NY. Feigenbaum, A.V. (1991), Total Quality Control, 3rd ed., McGraw-Hill, New York, NY. Flood, R. (1993), Beyond TQM, John Wiley & Sons, New York, NY. Gilmore, H.L. (1974), “Product conformance”, Quality Progress, Vol. 7 No. 5, pp. 16-19. Glare, P.G.W. (1983), Oxford Latin Dictionary, Oxford University Press, Oxford. Gronroos, C. (1984), “A service quality model and its marketing implications”, European Journal of Marketing, Vol. 18 No. 4, pp. 36-44. Hall, J.E. (2004), “Pluralistic evaluation: a situational approach to service evaluation”, Journal of Nursing Management, Vol. 12 No. 1, pp. 22-7. Hart, E. (1999), “The use of pluralistic evaluation to explore people’s experiences of stroke services in the community”, Health and Social Care in the Community, Vol. 7 No. 4, pp. 248-56. Hassan, D. (2005), “Measuring performance in the healthcare field: a multiple stakeholders’ perspective”, Total Quality Management and Business Excellence, Vol. 16 No. 8, pp. 945-53. Hudelson, P., Cle´opas, A., Kolly, V., Chopard, P. and Perneger, T. (2008), “What is quality and how is it achieved? Practitioners’ views versus quality models”, Quality and Safety in Health Care, Vol. 17 No. 1, pp. 31-6.
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Tafreshi, M.Z., Pazargadi, M. and Abed Saeedi, Z. (2007), “Nurses’ perspectives on quality of nursing care: a qualitative study in Iran”, International Journal of Healthcare Quality Assurance, Vol. 20 No. 4, pp. 320-8. Wan Rashid, W.E. and Jusoff, H.K. (2009), “Service quality in health care setting”, International Journal of Health Care Quality Assurance, Vol. 22 No. 5, pp. 471-82. Zabada, C.P., Rivers, A. and Munchus, G. (1998), “Obstacles to the application of total quality management in healthcare organisations”, Total Quality Management, Vol. 9 No. 1, pp. 57-66. Further reading Kelly, D.L. (2003), Applying Quality Management in Healthcare: A Process from Improvement, Health Administration Press, Washington, DC. Corresponding author Ali Mohammad Mosadeghrad can be contacted at:
[email protected]
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