The development of the quality movement in healthcare is recent, and can be traced to the IOM report Crossing the Quality Challenge. The IOM defined quality of healthcare in terms of six domains. These are safety efficiency, effective care, timely care, person care and equitable care, writes Dr. Peter Lachman.
Over the past 16 years the pursuit of quality care has mainly concentrated on patient safety and efficiency, which could include timely care.
Nowadays, person centred care is a major focus and there is a lot of good work in this regard.
Effective care has been a little problematic as it requires the development of evidenced based care clinical pathways and guidelines which then need to be followed. There has been little in the way of standardisation of care and many people are either over or undertreated. While we have concentrated on trying to make care reliable so that the person receives the right care the first time every time, this aim has not been achieved.
Services are now overburdened and this could result in a lack of efficiency, with people waiting to receive the care they need and often in an unsafe way. Nonetheless there has been a lot of progress though this is still fragile.
Perhaps as managers of services, we should reflect and assess whether the services we provide are equitable in name and in deed.
The final domain that was named by the IOM is equity of care and it is this domain of quality where there has been a distinct lack of progress.
An article in the NEJM catalyst Mate and Wyatt discuss the lack of progress in the domain of equity in the USA. It is true that the USA has wide disparities in the delivery of healthcare, particularly based on “race” and ethnicity, as well as class.
The USA reflects much of what we have in other countries where the underlying causative factor may be different. It may not be race but could be religion, or class or status. We like to believe that healthcare is available to all in an equal way particularly in the public sector. But like many other problems we need to make sure that care is both equal and equitable. Equity is something that needs to be confronted. Healthcare services are often designed in a way that they become inequitable. It is often where you live that determines what you receive.
In the NEJM article, based on the recent IHI framework, they suggest five key interventions which I have adapted for use in Ireland:
- Leaders need to make equity a priority – more in deed than in name. One cannot assume that services are equitable and leaders need to make equity a strategic aim.
- The services and structures need to be developed to support the delivery of equitable services; this is something that doesn’t just happen.
- Healthcare is not independent of the society and the determinants that result from political and societal decisions. We need to constantly examine these and their impact on service delivery.
- Institutional prejudice whether it be based on racism, sexism, classism etc. needs to be addressed actively always.
- Healthcare institutions need to partner with community structures to provide a comprehensive service; healthcare does not exist only in the walls of the healthcare facilities.
It is easy to read the articles emanating from the USA and say it does not happen here. Perhaps as managers of services we should reflect on the challenges posed by equity and actively assess whether the services we provide are equitable both in name and in deed.
There are numerous tools to assess equity. One may be surprised by what one finds and then one can implement a programme to make a difference. This is a challenge we cannot ignore.
