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Title: Understanding Quality Management in Eye Care Using Process Performance and Patient Perception
Authors: Arunkumar.A, Akilan
Keywords: Health care
C.A.K Yesudian
School of Health Systems Studies
Issue Date: 2015
Publisher: TISS
Abstract: Introduction "Quality" is one among the most fervently discussed topic in the e ver-growing healthcare industry, although discussions about quality and standardization prevailed even 2000 years ago. Improving quality of healthcare remains to be a challenge in many countries. Finding a definition, methods of evaluation, monitoring and quality improvement have been key issues of concern for healthcare professionals (Idvall etal. 1997).In the 20thcentury, as medicine and technology have advanced at a rapid pace,the health care delivery system has failed in its ability todeliver quality healthcare to all. Lack of choice and polarized demand-supply equation has contributed to the sluggish response of healthcare toward quality assurance. Increased knowledge and increased resources have not translated into better quality of healthcare. For example, health expenditure in industrialized countries has doubled in the last 30 years;however, the highest spending countries were not always those with the best results (Leatherman et al., 2004). A reason for this inefficiency may be the healthcare system focusing and acting on the parts than the whole. Taking a systems perspective, and orienting systems for the delivery and improvement of quality, are fundamental to progress and to meeting the expectations of the populations. Healthcare systems across the world have largely,realized this, and are in pursuit of improving the quality. The quality improvement approaches introduced in the manufacturing sector, such as Total Quality Management (TQM) and Continuous Quality Improvement, found their way into healthcare. Quality evolved from individuals to institutions; from tools to systems; from inspection to total quality management. Nevertheless, healthcare has come along way from there in incorporating newer dimensions of care to define quality.Comparing to other disciplines of medicine, Ophthalmology adopted quality assurance since 1980s. The first mention of quality assurance in ophthalmology appeared in medical journals in Australia, and USA in the 1980s (Carver 1985). In the late 1990s, studies of the quality of life as outcome measures of ophthalmic conditions (Hart, 1998), and patients' perspectives of their eye care (Nijkamp 2002) were published. In India, more than 15 million people are visually impaired (Dandona et. al., 2001), with cataract (62.6 %) and refractive errors (19.7 %) as the leading causes of visual impairment (Jose, 2008). India has achieved a tremendous success in solving the problem of blindness, especially cataract, which was the high prevalence blinding disease. The number of cataract operations has increased five- fold over the last 20 years. Today, Indian eye care systems are promulgated as models for high volume eye surgeries. Although significantly reducing the prevalence of blindness to 1.1 percent, and reducing cataract blindness by 40 percent, there are alarming concerns about the quality of eye care (Limburg, 1999). Dandona et al, (2001) estimates that the 3.5 million cataract surgeries performed in India in 2000 are to result in 0.3 million persons having irreversible blindness induced due to poor quality of surgeries. Policy makers and providers are shifting their focus from quantity to quality as the targets are achieved, and continuum of quantity is ensured. In the absence of nationwide data on outcome, these revelations pose great challenge to eye care providers. Eye care systems in India increasingly started deliberating on improving the quality of care over quantity in the last decade. Ravi Thomas (2000) points out that if outcomes and quality are ignored, the Indian eye care system is not only converting curable blindness to incurable, but also create adverse publicity to the national programme.Fortunately, in eye care, good quality is achievable in comparison to the other specialties, primarily for two reasons. Many eye diseases are curable with appropriate and timely management. For example, Cataract and Refractive errors, which accounts to about 80 percent of the visual anomalies (National Blindness Survey, 2001), are treatable and curable relatively with simple procedures and the patient could almost get his/her optimal vision provided standardized practices followed. Secondly, the outcome of the treatment procedures relatively easier to measure, monitor and improve due to the standardization of treatment processes.In a system perspective, a process is defined as a sequence of interdependent and linked procedures. Activities of a hospital fully comprise of processes. Improving processes offers a tremendous opportunity for hospitals to improve the quality of patient services and overall organizational performance. Unmanaged processes produce random results and high amount of variation from the standard, since protocols or guidelines are not in place. In these cases, the quality of care differs from patient to patient. Therefore, a system-based approach to measure process variations and improve them consistently is required for better quality of services. While choosing indicators of measurement, outcome indicators are considered as more stringent quality indicators than structural or process indicators because deviations from appropriate care should influence patients’health outcome; however they are difficult to define and infer. On the other hand, process indicators are often easy to interpret. Many are also easy to enumerate and do not require adjustment. Donabedian (1983) notes, “outcomes are no more valid measurement of quality than process, since validity resides not in the outcomes or processes themselves but the causal linkages between outcome and processes. Outcomes and process are in so many ways mirror images of each other”. The core ideas behind this facet of total quality are that organizations are sets of interlinked processes, and that improvement of these processes is the foundation of performance improvement (James W. Dean, 1994).While defining quality of healthcare, historically, there has been a disagreement between providers and patients. Clinicians believed that following standardized care and giving patients' optimal recovery from the illness means quality. However, patients’ placed greater emphasis on functional dimensions of care, such as communication, empathy, and timeliness (Gustafson et al., 1993). Examining a hospitalization through the patients' eyes can reveal important information about the perfor mance of the health care delivery system. Of late, an integration of technical (the quality of the delivery of care) and functional (how a patient receives a service) quality aspects are increasingly reflected in researches and become the two facets of service quality. Rationale of the Study The striking disparities in clinical outcomes raised serious questions about how physicians practiced medicine. Clinical epidemiologists in the 1970s deliberated whether variations in outcome were due to the differences in delivery of quality care.. Variation is an unavoidable part of the real world. However, the level of variation is the subject of concern, especially in healthcare processes. Within the available frameworks of quality measurement, such as process and outcome measures, outcome measures become relatively less and process measures relatively more useful when the perspective on quality narrows to hospitals and departments. This study aims to see how processes are managed in hospitals and their usefulness in provider’s perspective and whether it satisfies the requirements of the patient. Hence, process measures are the appropriate way of approaching this issue. However, process performance in eye care is still remains an unexplored area in ophthalmic practices despite their counterparts in other specialties has started exploiting the full potential of these measures. Specialties where care induced morbidity and mortality is taken seriously, have taken up process performance monitoring seriously such as cardiology, intensive care, and so on. However, it is easier to engage process management in eye care than other specialties, since practice patterns are standardized in most of the eye ailments and outcomes are measurable.Secondly, most of the existing studies are on stand-alone clinical processes. They concentrated on single process element such as use of aspirin during management of acute myocardial infarction. Studies with the holistic view of care delivery are very few and have come-up only in the last decade. There are number of studies that relate to process performance and outcome, and patient perception and outcome. Nevertheless, very few studies see the whole relationship as an inter-related function. If all core elements of quality are reviewed in totality that might give the holistic picture of quality of care.Finally, care bundles/ composite adherence score offers feasible and excellent models of monitoring quality and an opportunity to improve it. Since there are no care bundles or composite care measures developed for ophthalmic practices, this research may create an interest towards looking the worthiness of creating such a bundle.However, that depends or several factors which involves clinical experimentation, justification and ease of implementation. Purpose of the Study The purpose of the study is to understand quality of eye care by studying the relationships among process compliance, outcome patient satisfaction, and cost of non-compliance in out-patient and inpatient ophthalmic processes. Objectives of the study .To study the level of adherence to elements of processes and understand its implications on the overall process compliance ! .To find out the association between process adherence and final outcomeof the process (quality of service) .To understand the relationship between variation in processes and patient satisfaction .To understand the cost implications of variation (non-compliance) in processes. .To compare the relevance of process performance management for an outpatient treatment process (refraction) and a day-care surgical process (cataract) Research Design The study was designed with an objective to understand quality in eye care by studying the relationships among process compliance, outcome, and patient satisfaction in outpatient and inpatient ophthalmic processes. A causal chain linking interventions to outcome drawn from Donabedian’s theory is the basic framework of this study. The study explored the relationship between one factor with the other. This research was conducted in a tertiary care ophthalmic center in south India. The valid samples included in the study were 323 and 343, from cataract and patients with refractive errors respectively. Systematic random sampling method was employed to randomize the samples to be included. Patients having co-morbidity were excluded from this study. Only patients who had the possibility of regaining their full vision (6/6 and N5 in case of near vision), i.e best corrected visual acuity (BCVA), were included in the study. Tool construction The study employed two sets of tools; one to measure the level of compliance to process elements and the other to measure the perception of the care as felt by the patients. While dichotomous scale was used to capture process compliance, Likert scale was used in measuring the perception of patients relating to quality. To improve the validity of the process tools, first, a process map was developed in consultation with the ophthalmologists, and later the process map was converted in to a schedule. This schedule was evaluated by ophthalmologists and finalized. While developing this tool, standard protocols in the national and international eye care organiza tions such as WHO, IAPB, AAO, and NPCB were considered.
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02_Declaration.pdf32.94 kBAdobe PDFView/Open
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04_Contents.pdf53.17 kBAdobe PDFView/Open
05_List of tables.pdf46.48 kBAdobe PDFView/Open
06_List of Figures.pdf36.55 kBAdobe PDFView/Open
07_Acknowledgement.pdf42.39 kBAdobe PDFView/Open
08_Abstract.pdf134.86 kBAdobe PDFView/Open
09_Chapter 1.pdf380.94 kBAdobe PDFView/Open
10_Chapter 2.pdf824.28 kBAdobe PDFView/Open
11_Chapter 3.pdf285.68 kBAdobe PDFView/Open
12_Chapter 4.pdf358.1 kBAdobe PDFView/Open
13_Chapter 5.pdf290.26 kBAdobe PDFView/Open
14_Chapter 6.pdf122.44 kBAdobe PDFView/Open
15_Chapter 7.pdf148.29 kBAdobe PDFView/Open
16_Annexure.pdf72.91 kBAdobe PDFView/Open
17_Bibliography.pdf124.93 kBAdobe PDFView/Open

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