Towards Measurably Improving Healthcare Quality

By Dr Anja Smith

These expressed views are entirely those of the guest blogger/columnist.

I spent time in a private sector hospital toward the end of last year. I knew it was a (thankfully) rare opportunity for me, as a health system researcher, to observe what goes on in a hospital. But this time, it was from another perspective: as a patient.

From my arrival at the patient registration/check-in desk to entering the theatre and during discharge, I was cared for. All the healthcare workers I interacted with treated me with the utmost kindness and professionalism.

During my brief hospital stay, I was very aware of my privilege in South African society – because I have access to private healthcare. I thought about how people are most vulnerable when they are sick and need healthcare. And how all people need and deserve high-quality care, whether delivered in the private or public sector.

You hand control of your body and well-being over to other people, and you are not always able to insist on better behaviour or better healthcare from healthcare workers.

Here I’m writing about the clinical quality of healthcare, and healthcare acceptability. The two concepts are often intertwined.

Healthcare acceptability is about how patients are treated, ideally with respect and dignity. It’s also about how patients perceive and experience the environment in which they receive care. There are particular ways of measuring healthcare acceptability in surveys.

Clinical quality is more about whether healthcare workers do the correct thing: whether the information collected by healthcare workers is the right information, how that information is processed, the diagnostic tools used, and ultimately about whether the advice and treatment provided to patients are appropriate to their condition.

The two concepts are not unrelated. How patients feel, or experience how they are treated, greatly impacts their willingness to continue to engage with the healthcare system.

The General Household Survey, an annual survey of the population of South Africa, collects data on how patients experience their healthcare. During the Covid-19 pandemic, the standard set of questions on why patients bypassed certain facilities (related to poor experiences of care) were dropped from the survey.

However, from older surveys, we know that even when respondents are asked why they bypassed their closest facility when seeking healthcare, there are many complaints about how patients are treated there.

Even at healthcare facilities – where there is a focus on improving health quality – like the clinics participating in the public sector’s Ideal Clinical Initiative, quality problems continue to exist.

Why do unacceptably low levels of healthcare exist? And why does this continue despite system efforts to improve quality?

There are many reasons.  Here I share just three of them.

The first is that economists call healthcare a “credence good”. It is a product for which it is hard for non-healthcare people to judge the quality of the service provided. There can be huge complexity in producing good quality healthcare, and years of education and experience to increase necessary trust among healthcare users.

Because of this complexity, healthcare users cannot play a strong, or relatively strong, role in quality control by “voting with their feet”. Or at least, they are less able to do so than with other products or services.

Secondly, it is hard to measure the quality of healthcare. There are strong, good quality frameworks for quality measurement, like the Donabedian framework, which emphasises input, process and outcome measures. Inputs and outcomes are easier to measure. They are more tangible.

But process measures are hard to measure. Did the doctor or nurse ask the right questions? Did they assess all the information provided by the patient in the right way to arrive at a good diagnostic conclusion? Process measures are harder and more expensive to implement. Yet they are what often truly matters the most.

Lastly, accountability becomes hard to enforce because of the complexity of health (as a service or “good”) and difficulties in measuring quality. Who will hold the service provider accountable? Is it the sick patient and their family? The woman who has just given birth and was shouted at during the birth process, and who is now completely overwhelmed? These examples should clarify that health system users’ accountability is not easy. And that the responsibility of accountability will have to be passed on to a strong, external entity.

It’s good to end a piece like this on a constructive note. I’ve highlighted the problem and complexities of the issue. But ultimately, we need solutions. How can we fix bad quality healthcare?

The place to start is monitoring the levels and nature of healthcare acceptability and quality.

Is our health system geared to collect, pool and track indicators on the quality of healthcare? The long and short answer is no, not yet. We have pieces of data that allude to quality, but ultimately, they sit in unconnected data silos. We have some data for the private sector (from patient-focused surveys and clinical indicators). We have very little acceptability and healthcare quality data for the public sector, although efforts to collect data are underway. The public sector healthcare quality data has mostly emphasised input quality and doesn’t contain sufficient process indicators. Improving data is a process.

We need a strong, independent regulator – or regulators – to collect data on access and quality, and to do so across sectors (the public AND private sectors) so their relative performance can be monitored.

More solutions are available (like building strong positive organisational cultures that celebrate excellence, or localised solutions that enable innovation). I’ll write about these another time.

The starting point, however, is always just diagnosing. And at this stage, we are still quite far from accurately diagnosing the full extent of poor-quality healthcare in South Africa.