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Editorial
Medwave 2014;14(3):5935 doi: 10.5867/medwave.2014.03.5935
Integrando el mejoramiento de la calidad con la salud pública
Integrating quality improvement to public health
Vivienne C. Bachelet
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A few days ago, news surfaced on a situation regarding improvisation in the procurement of supplies and lack of clinical staff at a recently opened hospital under concession in the city of Santiago [1]. The new head of the health unit under which the hospital falls commented in the article alleging that the new hospital did not plan its purchases according to established population guidelines or to the complexity of demand. Something evidently went awry in the implementation of the clinical departments with respect to the construction of the health facility. It does not suffice to merely have the hospital; it is also necessary to have the management systems in place, along with the proper staff for providing health services that the population requires. This situation affects one of the capital’s most populous districts, seeing as the brand-new hospital was slated to provide for the health needs of over half a million people, who are now voicing their discontent [2],[3]. 

When people think of health, they mainly think of healthcare. And when they think of healthcare, what stands out in their minds is that it be timely and up to standards. In other words, they do not want long waiting times, and they want to be well treated. If these are the needs expressed by those who receive care within the health system, both from the public and private sector, the implication that these demands be operationalized as quality goals becomes obvious.

Quality? What exactly do we mean by “quality”?

Quality is a group of characteristics and attributes of a product or service that make it possible to satisfy explicit or implicit needs [4]. In turn, a quality management or continuous improvement policy can be focused on the area of individual care or on population-level public health. In either case, the starting point lies in establishing quality goals, which are the expected outcomes regarding providing care or in public health measures, the results of which are to be measured. Only with clear and known goals can uniformity in improvement measures and implementation be ensured. Likewise, it has become evident that mere dissemination within the health organization of the information pertaining to the performance of the quality goals does not ensure improvement initiatives in its own right. Clarity, communication among all parties, stewardship, and incentives are also necessary [5]. 

Nonetheless, quality can also be understood as a science, wherein a methodology is applied for the subject of enquiry and for standardizing knowledge. The science of quality improvement deals with identifying gaps in quality, applying courses of action, and monitoring the results [6], all of which must be known and understood by doctors and administrators [7]. When talking about quality gaps, we are referring namely to establishing the current situation, as well as defining the direction we wish to head in, which becomes expressed as… the quality goals that have arisen from detecting explicit and implicit needs. In order to travel this path, it will be necessary to ensure that the players involved within the organizational structure bear the tools that make it possible to take on the journey:

  • They must possess theoretical and practical know-how regarding the tasks they are entrusted with (information: do they know?)
  • They must have system as well as material resources at their disposal in order to accomplish what they are entrusted to do (infrastructure: are they capable?)
  • The disposition to get something done must be in sync with the result that is sought by the organization (incentives: are they willing?)

On the other hand, is it possible to intend to have homogeneous quality of health systems? One study attempted to identify a set of necessary attributes in organizational culture, regardless of context or surroundings, and which could be linked to success in implementing and sustaining quality improvement systems in health organizations [8]. It was concluded that “organizational coherence” stood as the critical element, which in turn has three key components: people, processes, and perspectives. Granted that the degree of commitment the communities themselves hold with regard to their health systems also plays a part [9].That very commitment is forged when the community participates in setting priorities involving health systems, which equates to participating in defining needs, which in turn determines the nature of the quality goals. These kinds of processes help to re-establish trust in the system by making the community an additional part in creating strategies so as to meet participatory-set goals. Ensuring that a strong body of abilities and support to call-on from other system levels is a must, including from the central area.

Efforts devoted to improving public health program effectiveness and efficiency are part of the quality improvement measures, yet on a population scale. A systematic review [10] identified measures taken on the organizational level; on the program or service level; and on the administrative or management levels. It was also revealed that few linked the measures to health outcomes or to health outcome predictors. The authors of the study concluded that the quality improvement results linked with proven public health measures and which quantify benefits should be identified, registered and disseminated. The dissemination of the experiences of these results ‒and which should also cover measures that didn’t produce favorable results- will be made easier if the recommendations from the Squire guidelines are observed [11].

In public health, lack of quality is expressed in consequences such as: lack of standardization in public health measures, variability, limited implementation of evidence-based strategies, shortage of properly trained interdisciplinary teams, lack of continuity in financing, and lack of timely and reliable data [4]. Three criteria have been prudently identified for defining the public health action priorities integrating a sphere of quality improvement: impact of the action, the ability of the action to improve over time, and that the action reduces the variability in implementation.

Without a doubt, a concerted, systemic, intelligent, informed, and equity-orientated effort is needed from all health system levels in order to ensure that everything that is done effectively satisfies the expressed needs, be they explicit or implicit, and on the target population, if only to make good on the expectation that people receive care within reasonable time frames, along with being well treated. Since this is not an easy task, it is necessary to think things out properly before carrying them out. As the mired hospital population knows, quality lies not only in having a new hospital. People, established processes and perspectives are also needed when going through those doors.

Notes

Conflicts of interest
The author declares no conflicts of interest with the subject of the article.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Autora: Vivienne C. Bachelet[1]

Filiación:
[1] Editora jefe, Medwave

E-mail: vbachelet@medwave.cl

Correspondencia a:
[1] Villaseca 21, oficina 702
Ñuñoa
Santiago de Chile

Citación: Bachelet VC. Integrating quality improvement to public health. Medwave 2014;14(3):5935 doi: 10.5867/medwave.2014.03.5935

Fecha de publicación: 4/4/2014

Ficha PubMed

Comentarios (1)

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Nombre/name: Christian Castillo
Fecha/date: 2014-04-22 13:20:48
Comentario/comment:
La verdad que no puedo estar más de acuerdo en la teorización de la adquisición de la calidad dentro del proceso sanitario, tanto dentro de los establecimientos y las personas que prestan estos servicios ("equipo" de salud), como de las organizaciones o los gestores en salud.
Efectivamente, las dos instancias recién nombradas se ven hoy sujetas a diferentes mediciones de indicadores de gestión, por el cual se califica a ambas, según gestión de "resultados"; estado financiero, n° de prestaciones otorgadas, n° de reclamos y si es que estos están contestados o no, etc.
Pero ante este sin número de evidencia uno se pregunta ¿dónde está el calidad de fondo?, ¿en la disminución de la lista de espera quirúrgica?,¿ en la disminución de los tiempos de espera?, ¿en el n° de funcionarios públicos con cursos de 20 horas?. Creo que la pregunta de fondo hace mucho tiempo se olvidó y podría enunciarse parecida a la que se plantea en el artículo, ¿estamos haciendo bien las cosas? y puedo intuir que hace rato que nos perdimos en dar la respuesta. Hoy estamos centrados en la imagen de los hospitales nuevos, de no aparecer en campaña de invierno con urgencias atochadas, o en el sistema privado, no aparecer con una demanda muy vistosa o sin perdidas para los accionista. ¿Entonces de qué estamos hablando de una carrera de indicadores de gestión o de transacciones financieras?, al final del día es saber si es que un equipo de salud integrado sabe o no sabe hacer bien las cosas( calidad técnica), podríamos resumirlo en gestión clínica o mejor en Clínica y gestión, enfatizando lo clínico.
En Europa hace ya un tiempo se responsabiliza a un equipo médico o a un establecimiento por el estado de su población , cómo tengo controlado a los diabéticos, lo hipertensos, los insuficientes renales crónicos y por ende todo se coordina para ello, en nuestro país existen indicadores con porcentajes de cumplimiento pero como metas aisladas o con esfuerzos aislados con aires de integrados. El tema es como pasar de saber la calidad técnica de los equipos de salud, a que después de tener certeza que son de calidad, implementamos las políticas de salud mancomunadamente, es decir retrocedimos muchos pasos atrás y tenemos que mirar ¿qué saben estos profesionales y cómo están formados?.
La realidad es que hay tema de calidad para mucho rato, la diferencia entre el conocimiento que abordan estos equipos de gestión es infinita, tanto en los equipos profesionales como administrativos y todo esto redunda en la atención directa al individuo que requiere de estos servicios, según mi humilde opinión este es el click, aquí es donde se produce en punto de inflexión, que lo hemos escondido bajo la alfombra hace varios años, el individuo que está realizando un acto médico ¿es confiable o no?, ¿tiene las competencias para hacerlo?, ¿es de verdad su certificación?, ¿en qué universidad o instituto estudió?, ¿será bueno? eso es lo que la población se pregunta al cruzar el dintel de un box de atención o de una sala de hospitalización. Hoy el sistema está intentando contestar esas preguntas con un grado de certeza, pero difícilmente se podría poner las manos al fuego por una respuesta altamente confiable.
El tema de los Hospitales y la implementación de las políticas públicas de calidad es otro capítulo.
Disculpen la lata.


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  1. Rojas C. Hospital de Maipú: insumos y remedios se compraron en forma directa por 680 millones y no podrían ser usados. La Tercera. 27 de Marzo 2014; Sección nacional [on line] | Link |
  2. División de Construcción de Obras Concesionadas. Programa de concesiones de infraestructura hospitalaria, Hospital de Maipú - Hospital de La Florida. 2013.[on line] | Link |
  3. Alcalde acusa que hospital concesionado de Maipú “es un desastre.” Cooperativa. 27 de Marzo 2014; Sección país [on line]. | Link |
  4. Honoré PA, Wright D, Berwick DM, Clancy CM, Lee P, Nowinski J, et al. Creating a framework for getting quality into the public health system. Health Aff (Millwood). 2011;30(4):737-45. | CrossRef | PubMed |
  5. Lemire M, Demers-Payette O, Jefferson-Falardeau J. Dissemination of performance information and continuous improvement: A narrative systematic review. J Health Organ Manag. 2013;27(4):449-78. | CrossRef | PubMed |
  6. McDonald KM, Schultz EM, Chang C. Evaluating the state of quality-improvement science through evidence synthesis: insights from the closing the quality gap series. Perm J. 2013;17(4):52-61. | CrossRef | PubMed |
  7. Cohen RI, Jaffrey F, Bruno J, Baumann MH. Quality improvement and pay for performance: barriers to and strategies for success. Chest. 2013;143(6):1542-7. | CrossRef | PubMed |
  8. McAlearney AS, Terris D, Hardacre J, Spurgeon P, Brown C, Baumgart A, et al. Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change. Qual Manag Health Care. 2013;22(2):86-99. | CrossRef | PubMed |
  9. Kamuzora P, Maluka S, Ndawi B, Byskov J, Hurtig AK. Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania. Glob Health Action. 2013;6:22669. | CrossRef | PubMed |
  10. Dilley JA, Bekemeier B, Harris JR. Quality improvement interventions in public health systems: a systematic review. Am J Prev Med. 2012;42(5 Suppl 1):S58-71. | CrossRef | PubMed |
  11. Davidoff F. The SQUIRE guidelines and how can they help you report on quality in health. Medwave 2014;14(2):e5901. | CrossRef |
Rojas C. Hospital de Maipú: insumos y remedios se compraron en forma directa por 680 millones y no podrían ser usados. La Tercera. 27 de Marzo 2014; Sección nacional [on line] | Link |

División de Construcción de Obras Concesionadas. Programa de concesiones de infraestructura hospitalaria, Hospital de Maipú - Hospital de La Florida. 2013.[on line] | Link |

Alcalde acusa que hospital concesionado de Maipú “es un desastre.” Cooperativa. 27 de Marzo 2014; Sección país [on line]. | Link |

Honoré PA, Wright D, Berwick DM, Clancy CM, Lee P, Nowinski J, et al. Creating a framework for getting quality into the public health system. Health Aff (Millwood). 2011;30(4):737-45. | CrossRef | PubMed |

Lemire M, Demers-Payette O, Jefferson-Falardeau J. Dissemination of performance information and continuous improvement: A narrative systematic review. J Health Organ Manag. 2013;27(4):449-78. | CrossRef | PubMed |

McDonald KM, Schultz EM, Chang C. Evaluating the state of quality-improvement science through evidence synthesis: insights from the closing the quality gap series. Perm J. 2013;17(4):52-61. | CrossRef | PubMed |

Cohen RI, Jaffrey F, Bruno J, Baumann MH. Quality improvement and pay for performance: barriers to and strategies for success. Chest. 2013;143(6):1542-7. | CrossRef | PubMed |

McAlearney AS, Terris D, Hardacre J, Spurgeon P, Brown C, Baumgart A, et al. Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change. Qual Manag Health Care. 2013;22(2):86-99. | CrossRef | PubMed |

Kamuzora P, Maluka S, Ndawi B, Byskov J, Hurtig AK. Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania. Glob Health Action. 2013;6:22669. | CrossRef | PubMed |

Dilley JA, Bekemeier B, Harris JR. Quality improvement interventions in public health systems: a systematic review. Am J Prev Med. 2012;42(5 Suppl 1):S58-71. | CrossRef | PubMed |

Davidoff F. The SQUIRE guidelines and how can they help you report on quality in health. Medwave 2014;14(2):e5901. | CrossRef |

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