Reflections

Citation

Gourlay, R. (2006), "Reflections", International Journal of Health Care Quality Assurance, Vol. 19 No. 1. https://doi.org/10.1108/ijhcqa.2006.06219aaa.001

Reflections

This is my last editorial as I have decided that nearly 20 years as founding editor is sufficient and the journal could benefit from fresh and different insights into health care quality. I sense that there are some exciting developments that are being introduced it and the new team of editorial staff will want to explore these – (more later in this editorial).

I have given myself some licence in this final editorial. It is more a stream of consciousness picking out those things that have had impact on health care quality – in my view. Others may disagree with my selection – I have no problem with this! Most of my thoughts are based on the British National Health Service, which is the one I know best and have worked in as a Director of Human Resources. However, many of the initiatives have come from elsewhere.

To begin my reflections, I start with “Quality Circles”. Groups of staff were invited to form a “team” that would investigate problems and exploit opportunities. They had a fairly short existence with the daily pressures making it difficult to hold meetings and with little support from the top, they naturally fizzled away. But they had put “quality” on the agenda.

Another, and perhaps more significant initiative was introduced by the British Standard 5750 which was to become the ISO 9000 series. The journal was, and still is a strong supporter of the standard, defining is it did a quality assurance management system. It had a stuttering start with very few institutions going the “whole hog” with the system. There were and still are a number of “departmental” institutions covering such organisations as catering, laundry, pathology services, pharmacies etc. And indeed whole hospitals built the standard into their everyday working; a number of these were outside the UK. We were delighted to publish these efforts to encourage others to build quality assurance systems at work.

A major benefit of ISO 9000 was the emphasis it placed on carefully drafted policies together with clear documentation. As a result, many health care managers now had a structure and language that enabled them to design their own approach to quality management.

However, there still remained a lack of support from the very top. Chief Executives were more concerned with financial matters than quality issues. It was one of the NHS’s frequent reorganisations that really brought quality issues to the top of the CEO’s agenda. This happened because it was ordained that the CEO had all over responsibility for “everything including clinical issues” and not just financial matters. To give real effect to this, the Department of Health and then eventually the Commission for Health Improvement introduced the “star” system. This really did expose the poor performer in terms of patient care.

A part of CHI strategy was to examine the delivery of care through the use of peer group analysis with practical recommendations being made from improvements which were carefully monitored thereafter.

The other force for change was the government’s own approach to public services and their management. This was and still is the use of standards and targets for health care provision. In my view, this probably set back the cause of “quality” in patient care. This is because the targets distorted clinical priorities and gave rise to a variety of mechanisms for concealing performance outcomes against targets. There were far too many targets in the first place so that managers had to select what to “go for” and leave “other things” for another day.

Another and perhaps more successful innovation was the National Institute for Clinical Excellence (NICE). Here we start to see evidence-based medicine at work. It also started to get away from “post code” lottery where a patient is in one part of the UK able to get drugs that are not available in other parts of the UK, most often for financial reasons.

As I have mentioned the British National Health Service has been subject to many government inspired reorganisations (few of which were evidence based!).

Recently, the department of health has driven itself into a schizoid position. With on one hand not wanting to interfere with the management of Trusts whilst still proposing and emphasizing targets.

One way of resolving this tension has been the creation Foundation Trusts which are free from central bureaucratic control and are allowed considerable scope in terms of financial and quality management. One aim of Foundation Trusts has been to involve the local population in determining their health care management policies and strategies. This is likely to give a much more powerful voice to the local consumers and customers.

One of the approaches of which I had high hopes was that of business process re-engineering (BPR). The scope for examining processes in health care must be legion and indeed there have been some notable successes in the improvement of the services to patients and reduction of financial costs both at the same time. I am still hopeful that out of BPR will become an even more powerful initiative. I refer to this in my last paragraph.

Returning now back to the journal where the main editorial worry used to be that the journal will not receive the necessary high standard articles for publication. I am pleased to say that this is now no longer a problem although we occasionally have the problem of too many good quality articles which means that it is sometime before authors see their work in print. We have tried to overcome this by expanding the pages in each issue of the journal.

One of the editorial delights is to receive articles from all over the World. Many of these describe the research work being done into quality management whilst others comment on clinical practices which have been re-shaped through more research and analysis.

Finally, I sense that the next major quality initiative will be what is referred to as Six Sigma. This is described in the abstract of a future article, which we intend to publish by Ken Black and Lee Revere of the University of Houston as:

Six Sigma is a powerful quality strategy that is taking hold in many healthcare organizations. Rooted in the principles of TQM, Six Sigma engages senior healthcare leaders and leverages resources to projects impacting patient outcomes and/ or financial gains. Six Sigma’s unique methodology refocuses variation measurement on statistical analyses while providing a metric by which process improvement can be gauged. Healthcare organizations implementing Six Sigma find it successfully fills the voids left by TQM and is drastically changing the face of their quality improvement initiatives.

In my retirement I shall look forward to reading and digesting this article and hopefully seeing the impact it has on both patient care and the bottom line.

I wish my successors well and hope they enjoy editing the journal as much as I have and a final thanks to all contributors over the last 20 years.

Robin Gourlay