This review first presents definitions of quality of care with frameworks, domains, characteristics or elements proposed to support the definition of quality. Secondly a few applications of such frameworks and models to establish a set of indicators in a specific health area are outlined. The third part reviews frameworks and models for patient satisfaction or client-centred care and introduces some important limitations of measuring patient satisfaction.
Quality of care is a multidimensional concept which has been defined by the Institute of Medicine as ”the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Further, six aims around the core need for high-quality health care were identified 1) safety, 2) effectiveness, 3) timeliness, 4) efficiency, 5) equity, 6) patient-centredness [180]. This is broadly similar to the European context frameworks in which the cornerstones effectiveness, efficiency, access, patient safety, continuity, acceptability, appropriateness, satisfaction, and patient experiences are used [181].
The utmost importance of patient safety as a core element of quality of care is highlighted by WHO and supported by the World Alliance for Patient Safety [182]. Thus thinking around quality of care is rooted in the Hippocrates Oath “First do not harm” dating more than 2000 years back. Another factor in conceptualising quality of care is the increased availability of
‘evidence’ in many areas of medicine as presented by the Cochrane Collaboration and related initiatives [183, 184]. Health system performance and quality of care can be seen a related concept as both i) assessment of quality of care and ii) health system performance are based on very similar frameworks and assessment criteria and both have, the highest attainable health, measured by impact indicators, as an endpoint [185].
Frameworks of quality of care which are predominantly based on the landmark work of Donabedian propose that quality of care should be assessed by including input, process and outcome indicators [186, 187]. This is similar to health system performance frameworks such as the one published by WHO and the International Health Partnership (also known as IHP+) [188]. Frameworks proposed for maternal and child health assessment also broadly follow this same model with assessment of progress along the effect line using input, process, output, outcome, and impact indicators [189, 190].
59 A few reviews have been published specifically looking into assessment models and conceptual frameworks in the field of maternal health. Morestin et al in defined key domains within a framework of structure, process and outcome for maternal care [191]. Some of the key domains, such as organisational resources as an aspect of structure are not routinely found in other frameworks but could be seen as aspects of health system governance and leadership [192]. A framework proposed for the assessment of skilled attendance at birth by Adegoke et al [193] follows the flow of input (in this paper called structure), process and outcome and divides the necessary inputs into i) availability of skilled attendants and ii) the enabling environment. Quality improvement and management aspects are categorized under processes and not in the category of inputs as proposed by Morestin et al [191] and in health system frameworks [190]. Many of the aspects listed under the ‘enabling environment’ could be categorised into the domains of the health system building blocks [18], indicating the close relationship between quality of care and health system thinking.
A recent literature review of definition and models of quality of care in maternal and neonatal health identified different models defining quality of care from five different distinct perspectives [194]. The first model describing “dimensions of the health system” is represented by the model of Donabedian defining structure, process and outcome [186].
Another model proposes “characteristics of quality” being accessibility, availability, affordability, equity and effectiveness [195]. Ovrevreit defined three main “perspectives of quality” being 1) client quality, 2) professional quality, and 3) management quality [196].
Others have used “elements of quality” ranging from elements of resources, referral and information systems to experience of care [197]. The elements of quality in family planning services by Bruce is another example which uses “elements of quality” model [198]. Raven et al [194] proposed to use all these five models of quality of care to assess the quality in maternal and neonatal care in a comprehensive way.
Based on these frameworks and models outlined above, health care areas, services units and departments have often established their own set of indicators specific to diseases and patients characteristics. Delphi methods with at least two rounds of expert consultations are used to define sets of indicators appropriate to the respective medical field [199]. Kötter et al [200] reviewed the literature on approaches used to select quality indicators based on guidelines and proposed a six step approach from 1) topic selection, 2) guideline selection, 3) extraction of recommendations, 4) indicator selection, 5) practise test and finally 6) implementation. Van Engen-Verheul et al [201] proposed a modified Rand Method including
60 1) expert and patient panels, 2) literature research and 3) review of guidelines. The innovative aspect was the inclusion of a patient panel.
Schull et al underlined the importance of using indicators where evidence exists that there is a clear link between process and outcome indicators, thus improvements in process of care result in better outcomes In addition indicators should reflect a potentially serious and common gap in health care performance [202].
In summary, a growing body of work has been published to conceptualise quality of care and to define frameworks and important domains to be included in assessments. Processes of indicator developments and selections are often – although not always - based on such frameworks and models. Literature reviews including evidence reviews, Delphi methods with consensus and consultation are commonly used to define final indicator sets.
Client satisfaction
Client satisfaction is increasingly seen as an important outcome of care; health systems and quality of care frameworks include satisfaction with care as an outcome indicator together with key health outcomes [190, 203]. Client satisfaction has been suggested as part of the indicator sets to define the ‘right to health’ [204].
Table 7 gives an overview about recent published papers (last five years) investigating patient satisfaction in different contexts. Some of the papers suggest how best indicators of patent satisfaction might be developed. Qualitative formative research [205, 206] and asking clients about the importance of each of the indicator [207] are aspects which are proposed by several authors. Particularly the publication from Sixma et al 1998 has guided several assessments of client satisfaction in different health areas in the Netherlands [208]. The domains included vary widely. Typically client satisfaction along different stations of health care seeking (admission, procedure and discharge) is assessed.
However, although satisfaction with care is an important outcome measure, it has been criticised for its subjectivity [209]. Investigations into assessment methods suggest that satisfaction is influenced by the interval between a health care service and the assessment of services [210]. Moreover client characteristics such as education or age influence patient satisfaction. Hekkert et al [211] recommended based on a multilevel analysis of patient satisfaction to adjust endpoint values of client satisfaction for age, health status and education when using such an indicator to compare different services. Jayadevappa et al [212]
hypothesised that satisfaction to be comprised of three dimensions 1) patient level attributes
61 2) satisfaction with treatment choice/decision and processes and 3) satisfaction with outcomes [212], thus also proposing that patient level attributes are important to consider.
Table 7: Studies investigating into client satisfaction Author,
year
Type of paper Clinical area Indicator domains Comments Bokhour et
Epilepsy Final list of patient-generated included
Referral to self-help groups
Sixma et al. Framework Rheumatic Indicators were rated by Authors underline
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Regional indicators (disease specific)
Attitude of the healthcare professionals
Information and explanation
Environment
Leaving the department
General information and rapidity of care
Tuberculosis Use of adapted 13-item patient satisfaction by 12 points all answered positively such as no problem with waiting time, ability to discuss with provider,
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Health care delivery
Health facility conceptual dimensions 1) Biopsychosocial perspective, 2) Patient-as-person, 3) Sharing power and responsibility, 4) therapeutic alliance, and 5) Doctor-as-a person [218]. The World Health report 2009 also strongly underlined the need to put the expectations and needs of the clients in the centre of care, and defines client-centred care as i) focus of health needs, ii) ensuring personal relationship iii) comprehensive, continuous and person-centeredness iv) shared responsibility within the community and along the life-cycle and v) patient as a partner [219].
Theses domains of client-centeredness could also be used to define important aspects of client satisfaction.
In summary, there is an increasing body of literature available on the importance of client satisfaction as an outcome indicator to measure quality of care and health system performance [190, 219]. Table 7 has listed publications which aimed to assess client satisfaction in very different settings. Morestin et al included in their review assessment tools to assess client satisfaction in the field of obstetric care [191]. Thus, much work has been done
64 in recent years to identify indicators and assessment tool. However, no internationally recommended definition of such an indicator of client satisfaction or a standard assessment has yet been identified [220, 221].
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