Select Reviews of Literature
This dissertation will be based on a literature review that will aim to gather a full range of ideas, examples, and existing practice from the heath care industry, focusing on homes that provide care for adults. It is anticipated that the major input to the information base will come from journal articles and government-based institutions where official documentation is available. Published books would be few in number in the UK, but international sources will be. Care home organisations and interest groups frequently hold conferences and may publish material internally. This could also provide informative research material.
The principal aim of this research will be to establish whether it is possible to draw together a general consensus of opinion about what is and what is not regarded as quality in care homes and whether a distinction between the two extremes can be defined – when is the line crossed, is there a line to be crossed, or does the grey area between make this an impossible objective to achieve?
National minimum standards agreed by the Government resulted in the regulatory body, Commission for Social Care Inspection (CSCI) being created in 2004 to inspect care homes to know whether minimum standards of care has been achieved (CSCI, 2004). The methodology originally used by the CSCI overlooked some quality of care issues that are critical in ensuring a good quality of life. The CSCI recognised this constraint and improvised this process by publishing a consultation document (CSCI, 2005) suggesting changes that would meet the Government’s 10 principles for inspection. (Office of Public Services Reform, 2003). The Department of Health acted on by changing the regulatory framework to allow a change in the frequency and type of inspections.
This change allows a higher frequency of inspections where standards are thought to be at risk of being, or actually, below required minimum standards (CSCI, 2006). Although the CSCI has recognised the problem and has taken steps to address their operational methods there is an opportunity to contribute to the knowledge bank through focused research. In general those who receive care in homes are much more vulnerable to poor quality standards and often lack the ability to take individual action to rectify obvious shortcomings – even if they are perceived. The approach adopted by the CSCI is to throw the onus on care service providers to improve quality, the assumption being that they will recognise weaknesses honestly and be prepared to act on them (CSCI, 2004). The proposed output from this research will aim to fill a perceived knowledge gap so as to facilitate the improvement in standards of care.
Project Design and Management – Literature Search
The initial work will concentrate on identifying potential areas where published research, guidance, or official documentation may be found. Potential sources will be identified and listed by a thorough review of websites and library material. Book abstracts, conference proceedings, journals, and statistical and official publications are likely to produce an initial indication of the information. Books will be located by searching catalogues, bibliographies, and citation indexes. An initial starting point will be the online public access catalogues at academic libraries where searches will be undertaken using, authors, titles, and key words to establish a list of potentially useful publications. The use of a well thought out search vocabulary that will be modified according to needs will help to ensure that most potential sources can be identified in this way (Hart, 2001). Journals will offer up to date sources of information and debate on “quality” and the related issues that this dissertation will need to cover. The main tool used will be a search of indexes and abstracts. As the area of interest covered by this research is currently developing and increasing the use of a current awareness service will also need to be considered in order to keep abreast of recent developments (Hart, 2001).
Conference papers and newspaper articles will be difficult to find using the traditional library techniques described above. It is possible to obtain conference material or references from the British Library (Hart, 2001) but a more productive approach for the topic area being research for this dissertation will be to focus attention on organisations or groups that are known to have an interest in it. Newspaper articles will give information about events that may need to be followed up separately – for example a change in Government policy or comments about public concern. Statistical and official publications are very likely to provide information to help understand current key issues and debates. Quality of health and social care is climbing the political agenda so Government Departmental information will be a good source, as will reports of parliamentary debates via Hansard.
Definitions of Quality
Quality represents something that people desire within products, services, and conditions. Nevertheless, to identify and measure features of quality is something that is rather complicated, depends on the context of discussions (Berg, 2001). “Quality” is an abstract concept that is applied in wide range of contexts. Crosby (1979) says, “Quality might not be what you think it is” and “Quality of life is a cliché because each listener assumes that the speaker means exactly what he or she, the listener, means by the phrase” (Crosby, 1979. p17). One general definition of quality is difficult to capture. A simple search on the Internet for “quality definition” reveals many different explanations of what quality might be when considered in different contexts. Some examples are: –
- Quality refers to the inherent or distinctive characteristics or properties of a person, object, process or other thing. http://en.wikipedia.org/wiki/Quality
- The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs. http://www.chesapeakebay.net/info/qa_glossary.cfm
- Meeting expectation and requirements, stated and un-stated, of the customer. http://www.vmec.org/glossary/
- Conformance to requirements or fitness for use. Quality can be defined through five principal approaches: (1) Transcendent quality is an ideal, a condition of excellence. (2) Product-based quality is based on a product attribute. (3) User-based quality is fitness for use. (4) Manufacturing-based quality is conformance to requirements. (5) Value-based quality is the degree of excellence at an acceptable price. http://scrc.ncsu.edu/public/DEFINITIONS/P%20-%20R.html
- The totality of features or properties of an entity that bear on its ability to satisfy stated and implied needs (the ISO 8402:1994 definition). http://www.nswfitc.com.au/a/1855.html
Moullin (2002) identifies that “many of these definitions give very different messages to managers about what quality really means” (Moulin, 2002. p7).
Developing Ideas on Quality
Juran (1989) describes prior to the 20th century, consumers assured that they obtained quality products by simple inspection on purchase in the market place. The industrial revolution and introduction of mass production techniques not only destroyed the livelihoods of many craftsmen, it also made quality products more difficult to buy with any degree of confidence so the inspection departments in factories were aimed at eliminating defects. The inspection departments later became known as quality control or quality assurance departments inspecting and testing the product to ensure a quality product (Juran, 1989. p6). The quality movement was started by the Japanese soon after the second world war in 1946 (Jackson, 2001) in attempt to compete in the international markets (Juran, 1989). As a result, the Japanese created a revolutionary approach to quality resulting in advantage over the western economies (Juran, 1989). Philip Crosby (1979, p9) published one of the first books on quality. Crosby defines quality as “conformance to requirements” in the sense that he suggested that “whenever you see the word ‘quality’ read ‘conformance to requirements’ (Crosby, 1979, p17).
By his suggestion collection and evaluation of data in non-manufacturing process are also needed to assess quality. The approach is to measure, monitor, and improve performance where products meet a standard, and quality assurance is assessment and deployment in direct comparison with a standard. The weakness with this approach is that if the specification is wrong then, although quality assurance targets may be met, the outcome may be of poor quality resulting in customer dissatisfaction, (Straker, 2001) which was not a criterion in the early days of quality development (Straker, 2001). Joseph Juran recognized this weakness and defined quality as “fitness for use” (Juran, 1989, p15) taking into accounts the needs and expectations of customers indicating that the manufacturers or service providers understand how a product or service might be used or experienced by an individual (Straker, 2001). He qualifies his own definition by saying “product features that meet customers needs” and “freedom from deficiencies” (Juran, 1989. p16).
Another definition developed specifically to address problems of defining quality in the health service is “Fully meeting the needs of those who need the service most, at the lowest cost to the organisation, with limits and directives set by higher authorities and purchasers”, (Ovretveit, 1992, p2). Ovretveit’s definition is an attempt to accommodate several different complex aspects of health care delivery into one where different people have different objectives and perceptions about quality. Definition of quality here gives an indication of measurable needs addressing three basic aspects of health care, the views and needs of patients, the objectives and opinions of professionals, and the over-riding need to achieve value for money by reducing waste and inefficiency culminating into the required outcome as a quality driven, professional service giving patients what they want and need at the lowest cost (Ovretveit, 1992).
Ovretveit’s concept of integrated quality development enables a complex service delivery organisation to achieve high quality in all three dimensions at the same time. The driving force behind Ovretviet’s interest in this field was a belief that the quality principles that had been developed had resulted in a “quality approach” which could be applied in health services and that “continual quality improvement comes from giving people new methods and skills…not from inspection and standard setting…” (Ovretveit, 1992. p1) ruling out bureaucratic NHS culture that adopts inspection and standard setting from above and overlooks the need to change human attitudes and behaviours. He also set out the need for quality improvement to be driven by the service provider in terms of organizational changes, not the customer.
Harvey (1995) described quality as “fitness for purpose” where this means the fulfilment of a specification or the achievement of stated outcomes. This defined quality in terms of fulfilling a customer’s requirements, needs, desires, or satisfaction, enabling the customer to specify the requirements to be achieved where fitness for purpose is measured against the ability of an institution to fulfil its mission statement (Harvey, 1995).
ISO 9000 generalises the definition to “the degree to which a set of inherent characteristics fulfils requirements” of stakeholders who are “customers and interested parties”(ISO 9000, 2000), thus applied in the healthcare field this involves not only patients, also their family members. Recent articles describe quality as being obvious when it is seen or experienced giving it a subjective approach. Harvey (2004) acknowledges that quality is thought by some to be too complicated to define in absolute terms despite the need to measure it as a controlling mechanism for those charged with ensuring an overall improvement in quality. Quality issues in the delivery of services such as health care are usually closely aligned with issues of standards. In the sphere of service delivery, these quality standards need to meet defined or acceptable level of service (CSCI), thus measuring the degree of standards met. These measurements, therefore, have little to do with quality but more to do with the gathering of information, which can be converted into outcome indicators for comparative purposes. “Qualities” are the expression of measurable parameters, whereas “quality” is the fundamental embodiment of character (Harvey, 2004).
It is clear that attempts to “measure” the quality of service delivery through the gathering of data in a statistical format and then comparing it against benchmarks or minimum standards cannot take into account the perceptions of individuals upon whom the service impacts. There is therefore a significant risk that even if standards are met the achievement of an acceptable level of quality cannot be guaranteed. It is critical that in order to ensure a good quality of service the correct parameters need to be chosen and appropriate levels set within them.
Many elders live the rest of their lifetime in care homes in the United Kingdom. This led to the origin of long-term care facilities like care homes and nursing homes. The older people deserve high-quality care committed to their well being. When talking about elder care, this means the provision of special needs of this age group and also means having the care delivered in a way that the elders desire and prefer and would more likely accept. The care home industry is often the origin of scandals and consumer dissatisfaction in terms of quality of care, and it has been postulated and recommended that the nursing home quality of care and staffing of qualified nurses be improved. Consumer demands have pointed to the needs of alternatives to care homes with quality care delivered to them in the setting of their choice.
To this end, research in order to improve delivery of care to the older adults is a frequently felt necessity so the care of the older adults becomes quality care, particularly in the setting of adult care homes. During the early nineties, local authorities were responsible for the regulation and inspection of residential homes within the public and independent sectors, the responsibility for the process within nursing homes resting with the local health authority. The regulation and inspection of care homes in this way resulted in inconsistencies between health and social services locally and fragmentation and variations in interpretation of regulation guidance nationally. There were also concerns that the local authority had the potential to lack an independent stance when inspecting or commissioning services from its own organisation (Means et al., 2003).
Clinicians, policy makers, and older persons themselves acknowledge that the primary goal of healthcare in the elderly, specially those who are chronically ill and frail with multiple age-induced illnesses would be restoration of comfort and optimization of function, rather than just treatment of individual diseases. Functional decline is recognised as a parameter of deterioration of health status of the elderly. In this age group, care parameters ideally would attempt to identify events that trigger functional loss. A quality care system in a care home would not only support, but also would venture to develop methods that would prevent or reverse the process. Episodes of acute illness and hospitalization are periods of high risk when functional decline tend to occur.
A statistical analysis would prove the point easily. During hospitalization, approximately 25% to 50% of the hospitalized older persons experience loss of functional independence. Only one-third of these people recover to pre-hospitalization functional level in about 3 months. Many older persons who decline during a period of acute illness are referred for home care services. Home care service, therefore, represents an identifiable time for instituting interventions that would aim to improve functional outcomes in older individuals. As has been already mentioned, home-care based care strategies were not clinically designed earlier, and there were no governing regulations from the authorities. As a result, the basic structure of care home health care had nothing to do with the concepts of quality control as is applicable for other healthcare providers. Recent legislations mandate the care homes to pay attention to the functional outcomes of the patients receiving care. Research has added its input so that this system needs information and assessment of outcome and its quality. As a result, providers would need to investigate approaches that would ensure quality of care in this setting.
The main two problems in the aged adults are dementia and fear of falling. Dementia occurs in 5% of individuals over age 65, and this rises to over 30% above 90 years of age. The Conservative Government of the day recognised that care services had developed significantly to meet increasing care needs reflected in population and demographic changes. The regulation of these services however, had not developed at the same pace, in fact some services, particularly around domiciliary care were unregulated having been introduced ahead of legislation (Means at al, 2003). This investigation will look to expand on the perceptions of individuals who are engaged in the provision of care and whether they regard outcomes as more important than the methods used. For example current inspection regimes have the potential to encourage an approach that focuses on meeting the formal regulatory requirement rather than encompassing the pathway that leads to the achievement of the measured target (CSCI, 2004).
It is widely appreciated that the quality of personal and health care can vary between the establishments that provide it. This research will aim to address the issues impacting on the effectiveness of target setting and measurement of quality of care. There is a need to look at this previously neglected area of research critically in order to address a recent increase in awareness of how various aspects of care are provided and monitored. Public awareness of underlying problems has been raised through recent press interest in a few exceptional cases. Womack (2006a) described recently in the Daily Telegraph how some care home residents were being denied human rights, failing to receive basic hygiene and nutritional care. Many professionals working the care environment also realise that they are not being provided with some essential tools to contrast and compare quality in the many facets of care delivery where such tools would be able to help improve working practices. Thus high-quality long-term care of the elderly people looks for a traditional care home with high standards of quality and new facilities with excellent provisions of care. Faced with the desire to influence the quality of care of the older adults, there is a perceived need to conduct researches in this area that would take into account the complex problems of care home care and measuring their qualities. The goal of such research would encompasses provision of findings in order to improve the quality of care of the care home residents and based on the findings, to develop a quality protocol for the care homes that would be able to measure the standards.
Quality outcomes, hence, would point to the key processes that contribute to the quality of care in the care homes. The concept of care quality is multidimensional; therefore, there are studies with multiple measures and usually multiple methods to measure several aspects of quality. In a care home, both resident and facility attributes of quality contribute to outcomes, and often, there is interrelationship between the two. The key processes in care delivery also influence both facility and resident attributes of care quality and also affects quality outcomes ultimately. As a result, there is a large volume of literature that depicts the study of processes of care delivery in order to determine the systems of care that are most influential to improve the fundamentals of care delivery to result in quality resident outcomes. Literature also suggest that feedback intervention studies and processes of care intervention studies targeted to staff can influence changes in key processes of care delivery and in improving resident outcomes and satisfaction that are important parameters in the quality process.
2.4 Customer Expectations
In the 1980s, Professor Noriaki Kano developed theories on quality that incorporated customer needs and expectations as parameters of quality measurement. He developed a model that differentiated between different types of attributes of a product or service that had a relationship to a customer’s perception of quality. Kano proposed that a product or service has three characteristics that define the level of quality. Basic Factors are the absolute minimum specifications and are taken for granted by the customer as being pre-requisites for the product or service being provided; Performance Factors that improve satisfaction in proportion to the level to which they are present – ranging from dissatisfaction for a poor or low level of performance to high satisfaction where performance is high. These characteristics are directly correlated to customer satisfaction. The third set of characteristics is Excitement Factors that increase satisfaction levels where they are (Moultrie, No date). Moullin’s explanation, “The quality of a service or product is not just determined by the customer’s reaction to it – it also depends on the customer’s expectations” (Moullin, 2002. p 24). He takes this further by explaining the “moment of truth” analogy introduced by Normann et al (1978) where the customer or the receiver of a service is at the point of realising what quality of service is being provided. The three outcomes: –
- The customer gets less than expected and is disappointed;
- The customer gets what is expected and is satisfied; and
- The customer gets more than expected and is delighted.
It is to be noted that these are not measurable in traditional terms. The moment of truth for products occurs on receipt of the goods and is an instantaneous reaction which has its impact over a very short period, conversely the delivery of a service, particularly in health and social care is ongoing and happens over a period of time, often many years, with many moments of truth within which to assess and appreciate quality. “There will be a large number of moments of truth that will influence service users’ perceptions of the service” and there is “a need to manage all these moments of truth to ensure they give customers or users a positive experience”(Moullin, 2002, p26).
2.5 The Quality Gap
There are also parallels between Kano and Moullin in describing the continuing need to improve service provision. Moullin refers to “Bridging the quality gap” (Moullin, 2002, p32) by appreciating that the expectations of service users and patients continually increases and that the services being provided also need to improve at a similar pace in order to avoid creating a gap between quality expectations and what can be provided. Kano describes this as the excitement factor becoming the basic need. (12Manage, No date). Parasuraman et al (1985) compare the expectations of customers regarding the service they expect to that actually received, defining the difference as a measure of service quality.
Parasuraman et al’s gap analysis (described in Moullin, 2002, p33) sets out a more sophisticated model that takes into consideration other factors that might have a bearing the creation of “The Quality Gap” or measure of service quality and enables an analysis as to how the gap might have developed. Moullin defines 4 basic ways in which a quality gap can be created. Firstly, it can be caused through a mismatch between what consumers actually want and what service providers or manufacturers believe they want. There is a risk of incorrectly translating needs, which are understood, into a specification or set of standards to be met that do not actually meet those needs. That is, providers are aware of the customer’s needs but do not address this adequately through poor specification setting or poor communication. Thirdly, the specification may be right but the service delivery or product falls short of it. This may be due to any number of reasons such as poorly trained or motivated staff or insufficient resources. The final gap occurs when a product or service sells itself on a set of qualities or promises that it then fails to deliver.
2.6 Products, services and public services
There are significant differences between ‘products’, ‘services’ and ‘public services’ and a different approach to quality issues is needed for all three (Gaster and Squires, 2003). Products are tangible and usually conform to a specification making them suitable for “quality control” techniques to cut down waste and ensure a final product that meets its specification whist ensuring maximum profit. Gaster and Squires describe services as intangible products (Gaster and Squires, 2003, p7), which produce a need to apply different criteria to assess quality. Gaster and Squires suggest that public service is different again in the way quality should be addressed. The profit motives driving private sector performance and the need to improve quality are replaced by the public service ethos, which relies on the motivation of individuals to serve the public, not for their own gain or profit.
2.7 Quality in Health and Social Care
Moullin (2002) looks at Juran’s definition of quality (Juran, 1986 and concludes that it is not applicable in the service sector, even though it can be useful in determining some of the more technical aspects of care, such as drug and equipment use. He also criticises Crosby’s conformance to requirements definition (Crosby 1979) because it does not take costs into account. Moullin suggests that “Meeting customer requirements and expectations at an acceptable price” (Moullin, 2002, p14) is more appropriate for health and social care. Moullin identifies that Ovretveit’s definition relies on “higher authorities” setting limits and issuing directives and the definition therefore assumes that these higher authorities genuinely have the commitment to or understanding of the needs, of service users and put their requirements at the forefront. If this does not happen then either Quality Gap 1 (no understanding of needs) or Gap 2 (understanding but no translation into correct specifications) already exists and users’ expectations or needs will not be met. Moullin addresses this weakness by amending his definition for social and health care to “Meeting the requirements and expectations of service users and other stakeholders while keeping costs to a minimum” (Moullin 2002, p15).
2.8 Current Methods of Measuring Quality in Care Homes
This investigation will look to expand on the perceptions of individuals who are engaged in the provision of care and whether they regard outcomes as more important than the methods used. For example current inspection regimes have the potential to encourage an approach that focuses on meeting the formal regulatory requirement rather than encompassing the pathway that leads to the achievement of the measured target (CSCI, 2004). There is a large debate about quality of care and about what should be taken into account in order to measure quality. According to Kruzich et al. (1992), quality of care can be defined both as an input measure and as an outcome. But actually how can we measure quality? The vital importance of measuring and monitoring healthcare quality cannot be questioned. Quantifying healthcare quality is a complex and challenging process. From selecting patient groups to guiding analyses and interpretation, the entire process of quality assessment requires judgment. Many methods in research have been used in order to measure quality. A simple quantitative measure of quality of care is constructed by the staff hours per patient per day (Fottler et al., 1981; Greene and Monahan, 1981; Elwell, 1984).
Other measures are the number of deficiencies (Nyman, 1989), the hospital readmission rates or the mortality rates (Lewis et al., 1985), and lastly are the subjective measures by Hay (1977). A more complex measure for accomplishing estimation of residential facilities multidimensions was generated by Moos and Lemke (1984a, b), who developed the MEAP (Multiphasic Environmental Assessment Procedure) in terms of four domains: policies and services, resident and staff characteristics, physical features and the social climate. Later on 1990, Shaughnessy et al. created another multidimensional measure. They used expert panels and categorised 27 patients’ problems in four groups (Shaughnessy and Kramer, 1989; Shaughnessy et al., 1990). Other measure by using interviewer rates, chart reviews and observations was created by Kane et al. (1983a, b). Moreover, Gustafson et al. (1990) constructed QAI (Quality Assessment Index). This index is multidimensional and uses expert panels of judges to develop components of quality each with three to seven subcomponents. Despite the large number of efforts to measure quality, in practise quality is, difficult to be defined and measured. Extensive research efforts are needed in order to develop appropriate and effective measures.
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