Capturing the true meaning of quality in health services

Research shows that despite frequent evaluations, a lot remains unknown about the quality of municipal health and care services.

Everyone wants good quality healthcare, but what exactly is quality and how do you measure it?

Is it to do with the waiting time for home care services? Or how many nursing home residents have had medical supervision in the past year? Or whether the medication lists have been checked recently?

"These are important aspects that are all worth monitoring. The problem is that quality cannot be easily reduced to a quantifiable value,"said Randi Olsson Haave, an assistant professor and PhD research fellow at the Norwegian University of Science and Technology (NTNU) in Gjøvik.

"See me as a person"

Haave is in the process of completing a PhD on quality in municipal health and care services in Norway, and the methods used to monitor it.

"What particularly stands out in my research is how much being seen and treated as a person impacts the experience of quality," she explained.

Or as one nursing home resident expressed it in one of Haave's research interviews:

"Please, stroke my cheek – see me as a person. I think it is really important. It almost brings tears to my eyes when I talk about it, because it means so much. If the [caregiver] comes in stressed, it makes me ten times more stressed. I immediately feel my oxygen intake drop. There is something about a person who sees you, the energy they give you. It means so much when you have breathing problems, like I do."

Haave explains that many of the users and residents she interviewed emphasized the importance of interpersonal relationships.

"It could be staff who were good at giving them their attention and creating good moments, or staff who were open and showed understanding. These moments helped them feel safe and cope with everyday life," said the researcher.

One resident Haave interviewed compared it to a kind of medicine:

"There are some [caregivers] here who are like rays of sunshine. It is like being given a magic pill every time they walk through the door."

A lot remains unknown about quality

The starting point for Haave's research is that a lot remains unknown about the quality of municipal health and care services. This is despite the fact that municipalities have been required to report annually to national authorities on 32 different quality indicators for over ten years.

"On the one hand, there is broad agreement that we need good ways to monitor the quality of healthcare services. On the other hand is the question of how best to do it," said Haave.

Currently, quality indicators are used to do this. According to the Norwegian Directorate of Health, a quality indicator is an indirect measurement, a pointer, that says something about the quality of the area being measured.

"An example of quality indicators in the municipal health and care services could be the time it takes from a decision on home care services being made to the users receiving the service," explained Haave.

Still a lot of uncertainty

Haave explains that quality indicators are meant to contribute to transparency regarding the quality of the services provided.

"The results are intended to provide the authorities with a basis for prioritization and should serve as a starting point for improvement work both nationally and locally. They are also intended to provide residents, users and relatives with information about the quality of the services," said Haave.

"Currently, there is still a great deal of uncertainty about the results, both locally and nationally. This is due to a combination of municipal mergers and different registration practices," Haave said

As mentioned earlier, Haave's research also highlights a gap between what the quality indicators measure when it comes to healthcare and what those who receive and provide care actually describe as good care.

Residents, users and relatives should be heard

Far too little is known about how those who receive care and treatment experience them, Haave says.

"None of the quality indicators used today measure the experience of or satisfaction with the care provided. Municipalities are required to gather this knowledge by asking residents, users and their relatives," said Haave.

Unfortunately, it turns out that many years can pass between each time municipalities collect this type of feedback, and when they do, it often happens through questionnaires that must be either mailed or submitted electronically.

"There are many people who are simply unable to do that. Many need help when answering these questionnaires, and as a result, the response rate is low," Haave said.

She believes that Norway needs to use other methods to a greater extent in order to document the quality of municipal health and care services.

Greater focus on the actual experience of care

Although the methods for monitoring the quality of health and care services have problematic blind spots, Haave does not believe the solution is to get rid of them.

The nurses and healthcare professionals I have interviewed want us to continue using quality indicators. They say the indicators provide them with important frameworks and goals. But they also emphasize that the indicators fail to provide a sufficiently accurate picture of the quality of the services they provide," said Haave.

Her recommendation is therefore clear:

"Greater focus must be placed on what the indicators currently fail to measure, namely the actual experience of treatment and care. To achieve this, we must also develop and use other methods to document quality."