Health Information Systems for Low-Income Countries: An Overview |
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II. Health Information and Health Service Quality
A goal of any health care system is the maintenance and improvement of health service delivery. This implies that health status of the clients who are the main beneficiaries of the service must be monitored both as individuals and as a population. Furthermore, the observations must be interpreted, policies must be established, and plans must be formulated and followed by means of appropriate actions. An underlying assumption of this process is that the proper application of health care service delivery has a positive impact on the health of the clients and their quality of life.
In an industrial environment, the process of maintaining a level of service would be called 'quality control'. The essence of quality control is to maintain a method by which a product is made or a service is delivered thereby guaranteeing a uniform and consistent output. Quality control employs a protocol for production monitoring and correction, that is, a feedback loop, but it assumes that there are a fixed number of known production controls that can be adjusted to predictably alter the output.
In the case of the health care system, it is insufficient to use quality control because the environment, service delivery organizations, medical technology, and expectations are in constant flux – the health care system is complex and is influenced by many factors that may not be easily controlled or may not even be well understood. Also, with the health care system, there is emphasis on improvement of the quality of health through improvement of the service delivery process.
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In the case of health care service delivery, the terms 'quality management' and 'quality assurance' are used. The quality management methodology encompasses that of quality control with an important added ingredient ... the production process and indeed the control protocol itself are monitored and subject to change in order to make improvements in the system output. The result is a system that can evolve to meet the changing demands of its environment. Figure II-1 shows the types of objects in the health care system and their interaction.
Health care quality management cannot occur without health data and information. An operational goal for quality must be that described by Donabedian: the best quality of health care (best outcomes) to the most people (clients of the system) for the lowest price (all resources). Treatment of this topic must, therefore, start with some definitions of what quality is and definitions of what one can manage in a quality.
What is Quality?
An operational definition of quality:
The state of being of an object or process that can be systematically distinguished, quantitatively and/or qualitatively, by an attribute or set of attributes inherent to the object or process. |
While we cannot allow socio-cultural values to define the quality of an object or process, we can allow socio-cultural values to determine what quality of an object or process is acceptable or not.
Quality is:
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objectively determined and quantifiable, |
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the property, attribute or condition of a process, thing or person that distinguishes it from the others and determines its nature, |
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a specific property or natural condition of a living or non-living being, |
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the characteristics of an object or process, and |
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the inherent attributes of some thing or process that we need to manage. |
Quality is not:
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subjectively determined or qualitative, or |
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"good" or "bad", "acceptable" or "unacceptable", "high" or "low". |
An operational definition of an object:
Any thing that occupies space for an indeterminate period of time and can be characterized by its qualities. |
Examples of objects are:
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people, patients, organs, cells, etc. |
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populations, communities, families, etc. |
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equipment and supplies |
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institutions, departments, etc. |
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cities, towns, homes, etc. |
Types of object attributes:
State - Attributes that identify the presence of an object in time. These attributes may change with time or as a result of being subject to process.
Capacity - Attributes that identify the capacity of an object to change over time. These attributes may change with time or as a result of being subject to process.
Any activity or set of activities that occupies time and transforms objects. (The transformation of an object characterized by a change in its presence, state and/or capacity.) |
Examples of processes are:
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procedures, services and programmes |
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management |
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planning |
Process attributes include:
Effectiveness - The ratio of the transformation that is actually achieved to them maximum transformation that is possible.
Efficiency - The cost (time, money, suffering, etc.) of a unit of transformation.
What is "Quality Management"?
Quality management is the control of the transformation of objects (measured as by changes in their qualities) through the monitoring, evaluation, and administration of processes that transform the objects. It is the process of moving toward, and maintaining outputs (objects) with particular and specified qualities. The objective of quality management is to be able to predict the transformations that an object will undergo as a result of being subject to a process. |
Example observations:
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The treatment for disease X cures patients in 40% of cases |
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According to the literature the treatment can cure in %80 of cases (efficacy)
Therefore:The treatment is only 50% effective. |
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The diagnostic process costs $500 per case. |
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According to the literature the treatment should cost $250 per case. Therefore:The efficiency of the treatment is 50%. |
Example quality management objectives:
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Achieve an 80% level of effectiveness. |
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Achieve an 80% level of efficiency. |
The quality management process is a model of the treatment protocol. It addresses the following questions:
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What is the problem? |
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What objects are involved and what are their significant attributes? |
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What processes are involved and what are their significant attributes? |
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How do the processes transform the objects? |
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What do we need to change and how do we change process? |
Why start a Quality Management Programme?
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We do not know the qualities of our objects or the processes that transform them. |
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We do not control the transformation processes. |
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We want to change the quality of the objects and the processes that transformation them. |
Health Information Systems and Health Care Quality Management
Accountability for the quality of health service delivery is heavily dependent on data and health information systems. There are several important functions that are supported by a well-designed and functioning health information system:
Quality Improvement - To support continuous quality improvement, it is necessary to collect not only outcome data, but also to process that data.
Planning, Policy and Management - These activities require information on the costs, efficiency and effectiveness of the services being provided.
Research, Teaching and Program Evaluation - Primary data collection is often required to support specific research designs.
Patient and Public Information - Users of the system need to be informed. They require outcome information about particular health care institutions, e.g., hospitals, or professionals such as surgeons. These people must be able to make informed choices regarding their own care. Also, the public needs information to correct and support perceptions about the health care system.
Clinical Decision Making - Health care professionals need patient data so they can make diagnoses and treatment decisions. Only a comprehensive health record such as that provided by a well-functioning computerized system can retrieve a full set of patient health attributes.
Decision, Information and Data Quality
The characteristics that describe how well decisions, information and data contribute to achieving their intended objectives are qualities. Attention must be paid to the characteristics, nature, and form of the decisions, information and data identified as affecting the activities being managed.
Decision Quality - Decisions are intended to cause change in the state (health, capacity, etc.) of an object (patient, population, program, institution, etc.) or in the performance (cost, speed, effectiveness, efficacy, etc.) of a process (diagnosis, treatment, immunization, screening, etc.)
Measures of decision quality are its:
Focus - How well, qualitatively, does the decision address its objective?
Impact - How well, quantitatively, does the decision address its objective?
Cost - What resources are consumed to produce the decision?
Information Quality - Information is structured data that has been combined or processed for better interpretation. It describes the state or changes in the state of an object or a process. It is information only if it is useful in making a particular decision.
Measures of information quality are its:
Content - What is the difference between what is presented and what is required (missing information and superfluous information)?
Timeliness - What is the elapsed time between when the information was needed for decision making and when it became available?
Availability - Is the presentation of the information convenient for decision making?
Precision - Is the level of detail presented appropriate, or even possible, for the level of detail required? TIP: Information can be less than, or as precise as, the data on which it is based but it can never be more precise.
Accuracy - What is the difference between the information and the truth? Note: Inaccurate information can be produced from accurate data; it may be simply that the data processed are not correct components needed for the information or it may be that the algorithm used to produce the information is inappropriate.
Cost - What resources are consumed to produce (process and present) the information?
Data Quality - Data are facts about an object or process/event at a particular point in time. Good data is present, accessible, accurate and sufficiently precise. Factors that have an impact on data quality are:
Priority - How important is the data in producing the information.
Age - How long ago was the data measured?
Access - How difficult is it to include specific data in a process that produces information?
Precision - What is the granularity, i.e., level of detail, of the data? For example, the age in measured in years is less precise than the age in months.
Accuracy - How close is the data measured to reality?
Cost - What resources are consumed to collect and maintain the data?
Indicators are information based on variables (data) that indirectly indicate the state of a process or object of interest. They are calculated rather than measured and have value only when compared with a previous value or a base comparison. Indicators are used in the management and planning of health programmes, services and activities. |
A good indicator:
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must validly represent the quality or state of the process or object of interest. There must be a strong correlation between the data variables used to calculate the indicator and the conditions being assessed; |
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must be easy to calculate and the information must be reliable and accurate; and |
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must be calculated using data that is readily available, easily collected and inexpensive to collect. |
Outcome Indicators
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Outcome indicators are used as a measure of the efficacy and effectiveness of health care activities. Outcome indicators usually have population numbers as the denominator. A generic formula for an outcome effectiveness indicator is:
An example of an outcome indicator is, for example, the infant mortality. This is a ratio of infant deaths per 1000 live births.
Process Indicators
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Process indicators are used as a measure of the efficiency, efficacy and effectiveness of health care activities. Process indicators usually have resource consumption (time, money) as the denominator. The most common indicator for resource consumption is efficiency.
The occupancy ratio for a hospital is an example. The numerator of this ratio is the daily average number of inpatients, the "impact", and the denominator is the total number of beds available in the facility. The denominator has a cost implication because of the institutional overhead.
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© 2005 Canadian Society for International Health and the Contributors last update: 2005-06-28 |
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