Health care systems are used at many situations to cure illness, prevent health care problems, and reduce the pain and many a times to get information related to health conditions. This assignment starts with the introduction about the improvisation of the quality in such health care systems like hospitals and care centers. The second chapter explains the social construction of the quality of the health care system as they are more responsible for the health of the public. The Social construction of the health care quality is explained in detail along with the various steps in improvising the life health of the public. Taking into consideration of various factors like government, international agencies, the better improvement of the social construction have been explained with the help of various economists’ ideas and facts.
This chapter also explains the improvement of daily, tackling the health inequity and helps to interpret the problem and take necessary action towards improvisation. The third chapter defines various definitions and terms that are related to the health care and the quality of health care. It also explains about the factors that are used to measure the quality of health care. The fourth chapter deals with a quality improvement intervention taking Balance Score Card into consideration. The various processes that are required for a proper balance score card are explained in detail. This chapter analyses the similarities and variations in Balance Score Card with Health Care along with its limitations. A SWOT analysis is provided in the end along with the conclusion explaining the entire health care system and its advantages and disadvantages.
The aim of this assignment is to improve the quality of care within an organization especially the heath care units like hospitals, primary care centers or tertiary care centers. The health care services are used for many reasons like mending the breaks and tears, curing the illnesses and health conditions, preventing or delaying the health care problems in the future, reducing the pain and increasing the quality of life and sometimes to get the information about the status of the health and medical prognosis (Detmer, 1994). In this assignment, I have first discussed about the social construction of the quality of the health care units and their services to the people. Then I have critically examined the definitions of the quality and the services provided by the health care units. Before getting deeper into the analyses of the definitions, services and quality of the health care system and their advantages and disadvantages in the process of quality improvement, I have explained the current scenarios and the way to build a bridge to reduce the gap for a better quality future. In the past decades, identifying causes of disability and diseases, discovering cures and treatments, educating the public by working with the practitioners to reduce the prevalence and incidence of greater diseases have been made by the public and private organizations. Guidelines for the clinical practices have been introduced to influence and follow the practices. Campaigns that urge the public to comply with the treatment regimens and behavioral recommendations help in preventing and controlling the diseases and their consequences (Lumsdon, 1992).
Considering an individual, illness in health strikes randomly where as at a level of populations, health is closely related to the circumstances and the ways of living like prosperity or poverty, unemployed or employed, rural or urban, and contentment or stress and thus health and illness can either be categorized under social or biological facts (Blaxter, 1996). Alternative approaches like critical psychology, disclosure analysis, discursive psychology, deconstruction, post structuralism are now referred as social constructionism which is more important when it comes to the health care system behavior (Burr, 2007).
The chances of life vary with the birth and the death rate. People born in Japan or Sweden are expected to live above the age of 80 where as the people in African countries are expected to live less than 50 years. And even the chances of life differ within countries also. The higher level of illness and pre mature mortality are more in the poor people but not the poor health. Health and illness complies the social gradient where in the socio economic position is directly proportional with the health (Marmot, M. et al., 2008). The structural determinants and daily life conditions forms the social determinants of health and health equity which are not the social and economical policies, but are the fundamental results. These social determinants can be maintained by the government, local communities, civil societies and international agencies. The health gap in the generation can be closed by improving the daily life conditions, tackling the distribution of money, power and resources in places globally and locally, raising public awareness by measuring the problem and evacuating action to expand the knowledge base (CSDH, 2008).
Though the social determinants emphasizes the importance of the development of the early child which includes the physical, linguistic and cognitive development, they should be taught about the importance of social and emotional developments (McGregor, 2007). The government and the international agencies should be able to create a comprehensive approach to build programmes on child survival and interventions to the socio-emotional developments which in turn builds the health equity from the start of life. High quality primary and secondary education should be provided for all the children to improvise the education system to teach the needs of the social development (McGregor, 1991). The originator of the important health determinants is work which provides social status, financial security, personal development, social relations and physical and social hazards protection (Muntaner, 2007). Temporary workers have more possibility for earlier mortality than permanent workers (Kivimaki et. al., 2003). A provision for the living age to protect the workers can be provided by the employment policy. International agencies can also support to improvise the standards of the workers by developing the policies and ensuring the work and home balance. Policies which reduce the exposures of material hazards and health damaging behavior for the workers are also required.
The standard of low living is a powerful determinant for the health inequity. The other determinant of health is the health care system which is influenced by the social determinants. The benefits and experiences of health care relate gender, occupation, education, income, place of residence and ethnicity (Gwatkin et. al., 2005). The best health outcomes are from the health care systems when they are based in primary health care. Emphasis on both the local action for the social determinants like preventing and promoting and on the primary cares where adequate care is given to the higher level of health care (Marmot, M. et al., 2008).
The health and the health equity can be affected by the government and the economy. To improve the health inequity, coherent actions should be taken by the government like finance, housing, education, transport, employment and health (Kickbusch, 2007). An example where the health sector should take actions is the traffic injury which is a public health issue. Health and health equity must be made corporate issues so that the government places the entire responsibility to actions at a higher level and ensures the coherent conditions. The health ministers are more responsible for the stewardship and action by the government. The new technologies and the goods and services to improve the standards of living can be provided by the markets to improvise the health benefits. The inequities in the gender are permeant in all the societies. The governments, international organizations, donors and civil societies can promote the gender equity (Marmot, M. et al., 2008).
The major central social determinant to the health is Empowerment. To achieve the best standards of health, the material, political and psychological empowerment from the social inclusion is necessary (Farmer, 1999). Finally, the difference between the health and the people’s life chances reflects the power imbalance. The international community should commit a system where all the countries with the rich and the poor engage with one voice (Marmot, M. et al., 2008).
The basic data systems should be made available and the mechanisms should be ensured understandable to develop effective and efficient policies and programmes which in turn creates an effective action on the social determinants of health. Actions on the social elements need to build capacity among the practitioners and train the policy makers. A system to monitor the health equity and social determinant should be made available locally as well as internationally (Marmot, M. et al., 2008).
Closing the gap in the generation has two answers. The first is the coherent action which must be implemented across all the elements removing the structural inequity and ensuring more immediate well being. The next is the long-term agenda which requires investment and major changes in the social policies, political action and arrangements in the economy (Marmot, M. et al., 2008).
The greater demand for the health care has created more interest to improve the quality of health care. Health care can be defined as the composition of health care systems and actions that are taken to improvise the health and well being. The health care can also be divided into three parts namely the structure of health care, the process or the actual care given and the outcome or the consequences from the health care system (Steffen, 1988; Tarlov, Ware, Greenfield, Nelson, Perrin & Zubkoff, 1989; Baker, 1995; Irvine & Donaldson, 1993).
Structure can be defined as the health system which provides care also referred as organizational factor (Donabedian, 1980). Structure is composed of two domains namely physical characteristics and staff characteristics. The features of the structure provide opportunities for the individual to obtain care but it is not guaranteed. Though structure increases or decreases the likeliness to receive quality care, they are indirect and contingent. Yet, structure has a direct impact on process and outcomes when they are featured within a system based model (Donabedian, 1988, 1992).
The interaction between the user and the structure of the health care are actually defined as the Process. The Process of care given is composed of two processes namely interpersonal interactions and technical inventions (Blumenthal, 1996; Donabedian, 1988, 1992; Irvine, 1990; Tarlov et al., 1989; Steffen, 1988). Technical care is defined as the diligence of clinical medical to the health problems (Donabedian, 1980). The aspects of the behavior of the health professionals describe both clinical and technical care., but then the term clinical care will be more appropriate to be used as there are also technical aspects to the inter personal care. The interaction between the health care professionals and the users is known as interpersonal care. The clinical and the interpersonal care are more relevant for the process of consultation which applies to acute, chronic or preventive care (Brook, McGlynn & Cleary, 1996; Schuster et al., 1998).
The consequences of care are known as outcome. Outcomes may be directly or indirectly influenced by the structure or processes. Outcome has two principal domains based on the effectiveness of the structure and processes namely health status and user evaluation (Rogers et al., 1999).
Thus care can be defined as the system which is based on a model comprised of the structures of health and two care processes namely clinical and interpersonal which will result in consequent outcomes(Donabedian, 1980).
Quality is a term which can be expressed or defined in a number of ways and in a number of approaches. The quality definitions are either generic or disaggregated. The generic definitions are those which include excellence, expectations, goals that are met, zero defects or fitness (Ellis & Whittingham, 1993; Steffen, 1988; Crosby, 1979). The disaggregated definitions are those which are complex and multidimensional which are defined according to the individual components or dimensions (Donabedian, 1980; Maxwell, 1984; HSRG, 1992; Winefield, Murrell & Clifford, 1995).
The quality of care for the individual patients can be defined as the care where individuals can access the structures of health and the care processes they are in need and effective care is received. Quality of care for the population can be defined as the ability to receive effective care on continuous and efficient bases for the health optimization for the entire population (Campbell et al., 2000).
The quality definition exemplifies the complexity of the concept and its evaluation. In designing an aligned national strategy, the complex dynamics of health care delivery must be ensured, the different levels at which care might be valuated, and the different views of the key stakeholders in the system are represented adequately. To recognize these objectives, six challenges should be addressed which includes identifying and balancing the competing perspectives of the major participants in the health care delivery system, developing an accountability framework, establishing the explicit criteria by which health system performance will be judged, selecting a subset of indicators for routine reporting, minimizing the conflict between financial and non-financial incentives and quality-of-care objectives and facilitating the development of information systems necessary to support quality monitoring. The first two challenges explain the framework within which quality assessment should be conducted. The third and fourth challenges explain the quality measurement work plan. The fifth and sixth challenges recognize factors that inhibit advancement in improving and measuring performance (Campbell et al., 2000).
When it comes to Quality monitoring, maintaining the checks and balances to control the rising health related issues like financial and organizational mechanisms are critical. These strategies can be insensitive along with clinical application which means that care generally is removed when cost controls are brought in. Though the payment for the services that has no health benefits are not supported by anyone, it is impossible to determine whether routine monitoring prevents it or not. Thus, Quality monitoring is every essential to optimize resource allocation decisions in the health care systems (Campbell et al., 2000).
Balanced score card integrates the analysis of stake holders and performance management with suitable measures (Neely et al, 2000). Since hospitals across the world transform their management devices to increase the quality, their ability to leverage the intangible assets (credibility among patients) has become very important. The balanced score card complements this need by providing four measurement perspectives to increase the quality of business processes, learning and growth (Kaplan and Norton, 1996). The type of measurement perspectives includes Long term & Short term measures, Internal (business processes, learning and growth) and External (customers and shareholders) measures, desired outcomes, performance drivers & actual outcomes and Subjective & objective measures.
Balanced score card should be used as a learning and information system using communications rather than a form of a controlling system to increase the quality (Kaplan and Norton, 1996).
Management of hospitals does not need to rely on only financial results to measure their performance. The Balanced score card introduced four management processes which needs to followed either separately or in any combination to produce better results in achieving long term and short term objectives (Aide mark, 2001).
Irrespective of best intentions of top management, the lofty management words about a vision is not normally passed on to the lower level workers which results in confusion in understanding the objectives of both of these work groups. This issue needs to be addressed by providing understandable or actionable words integrated towards the vision (Kaplan and Norton, 1996).
In most of the cases, individual departments in a hospital will function individually towards a short term financial goal. But balance score card demands each department to work towards a larger goal or a long term vision. Increased interaction between departments will no longer focus on small financial benefits but on a long term vision to increased performance (Kaplan and Norton, 1996).
Business planning being one of the best achievement while using balance score card. Using balance score card allows proper planning of resources and prioritizes the objectives based on the larger goal of the organization. So there will not be any confusion neither in resource allocation nor in the objective prioritization. It reduces conflicts between top management executives; thus increasing co-ordination between the executives to achieve a greater objective (Kaplan and Norton, 1996).
Existing feedback system helps only to measure financial goals against performance of employees, departments or the company. On the other hand, score card based feedback system helps us to understand how each short term goal is achieved. Also it will be an imperative tool for greater learning experience. The score card also helps us to modify the strategies to achieve the goal on seeing the results (Kaplan and Norton, 1996).
Linking rewards to balanced scores proved to be an efficient way to motivate stakeholders. Normally a high achievable score is attached to a monetary award such that the stake holders are attracted towards it. When each of the stake holders works towards achieving such high score in the score card, the overall high score helps the company to achieve its goal (Kaplan and Norton, 1996).
In health care, reliability and precision measurement is not always possible. Ouchi (1979) said that measurement based management likely to attach reward to non-adaptive behavior which is likely to cause problems in health care centers. It will eventually decrease the quality of treatments. Even measurement of health care activities is questionable. But some of the doctors feels that balanced score card helps to measure the health care activities with their complex nature of measuring all aspects not alone the financials. This helps the doctors to understand their performance in all aspects irrespective of meeting their financial goals. BSC is based on the ‘golden triangle’ which consists of hospital, patients, employees and processes along with the consideration of financials. Balanced score cards tend to attract medical professionals and managers for better management of hospitals.
Aide mark (2001) formed a SWOT analysis based on meeting with professions who were working with BSC. The below table is reproduced from his work:
Courtesy: Aide mark (2001), Page : 32.
Though there were limitations, Balanced Score Card is an attractive tool which helps lots of health care professionals and managers to measure and increase their performance and quality. Gradually the tool is being used at hospitals for reducing the uncertainty in goals. With development across the health care sector, there is a need for future research to better understand the uses and limitations of balanced score card. The concept of balanced score card is widely accepted by the health care industry and organizations which provides healthcare. We can conclude by saying that balanced score card is an effective quality system which can be made useful to health care industry with some modifications required by the realities of the industry. And also the system is currently in use in a wide number of organizations in health care. Even the applications of balanced score card reached beyond strategic management. In the current scenario, the quality technique has undergone various changes to include health care perspectives such as access, outcomes and quality of care. It actually increased the need for timely information which is comprehensive in nature (Norreklit, 2003 & Aidemark, 2001).
The social construction of the higher quality of the health care units and their services for the people in terms of various steps in improvising the life health of the public should be taken care by the government or the international agencies, donors and civil societies. The quality of the services, the improvement of daily life, tackling the health inequity and the way to interpret the problem and take necessary action towards improvisation should be taken care by the system. Two different suggestions were given to reduce the gap for a better quality life in the future namely the coherent action and the long term political arrangements. The health care services be it the front offices that handle and give access to patients, or the treatment that is provided to a patient and the outcome generated through treatments needs to be measured so that it can be improved upon it. Having a quality measuring technique in place will develop willingness to increase the standards of stake holders’ work.
To know our quality systems are producing improvement, we need standard and accurate measurement to estimate the quality of work. Strategies for managing health care quality have its own importance and implications for the stakeholders in the system. They not only differ in the way the quality is measured, the incentives obtained through these techniques are different from one another. However, it is very true that what is measured gets improved; thus making it necessary to measure the service levels of health care facilities. The Balance score card can be recognized as a better tool for the health care professionals to increase and improvise the standards of the health care system. Balanced score card helps organizations to achieve consistency in their vision and improvise actions towards a collective vision; thus helping the organization by making it flexible to follow new processes and strategies which will help to achieve the ultimate goal. It actually provides framework which allows easier implementation of any new strategy or process which could result in organizational improvement especially in quality.
References
Aidemark, Lars-Goran. (2001) The Meaning of Balanced Scorecards in the health care organization. Financial Accountability & Management, 17(1), 0267-4424.
Baker, R. (1995). Practice assessment and quality of care. RCGP Occasional Paper 29, RCGP.
Benach J, Muntaner C. (2007) Precarious employment and health: developing a research agenda. J Epidemiol Community Health, 61: 276–77.
Blaxter, M. (1999). Risk, health, and social research: Lessons from the ERSC programme on risk and human behavior. Health, Risk & Society, 1(1), 11-24.
Blumenthal, D. (1996). Quality of care – what is it? N. Engl. J. Med., 335, 891-894.
Brook, R. H., McGlynn, E. A., & Cleary, P. D. (1996) Measuring quality of care. N. Engl. J. Med., 335, 966- 970.
Burr, Vivien (1995) An Introduction to Social Constructionism. London: Routledge.
Campbell, S.M., Roland, M.O. & Buetow, S.A. (2000). Defining Quality of Care. Social Science & medicine. 51 (1), p1611-1625.
Commission on Social Determinants of Health. CSDH final report: closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health.
Crosby, P. B. (1979) Quality is free – The art of making quality certain. New York: McGraw Hill.
Detmer D, Gelijns A. (1994) A more cost-effective treatment strategy. Arch Surg 129(2):123–27.
Donabedian, A. (1980) Explorations in quality assessment and monitoring. Volume 1: The defnition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press.
Donabedian, A. (1988) The quality of care: How can it be assessed? JAMA, 260, 1743-1748.
Donabedian, A. (1992) Quality assurance in health care: a consumers’ role. Qual. Hlth Care, 1, 247-251.
Ellis, R., & Whittington, D. (1993). Quality assurance in health care Ð A handbook. London: Arnold.
Farmer P. (1999) Pathologies of power: rethinking health and human rights. Am J Public Health: 1486–96.
Grantham-McGregor SM, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. (2007) Development potential in the fi rst 5 years for children in developing countries. Lancet; 369: 60–70.
Grantham-McGregor SM, Powell CA, Walker SP, Himes JH. (1991) Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. Lancet; 338: 1–5.
Gwatkin DR, Wagstaff A, Yazbeck AS, (2005) Reaching the poor with health, nutrition, and population services. Washington, DC: World Bank.
Harvard Business School Press, Boston, MA.
Irvine, D. (1990). Managing for quality in general practice. London: Kings Fund Centre.
Irvine, D., & Donaldson, L. (1993). Quality and standards in health care. Proc. R. Soc. Edin., 101B, 1-30.
Ittner, C. D. and D. F. Larcker. (2003) Coming up short on nonfinancial performance measurement. Harvard Business Review (November): 88-95.
Kaplan, R.S. and Norton, D.P. (1996) The Balanced Scorecard: Translating Strategy into Action,
Kickbusch I. (2007) Health promotion: not a tree but a rhizome. In: O’Neill M, Pederson A, Dupere S, Rootman I, eds. Health promotion in Canada, 2nd edn. Toronto: Canadian Scholars Press.
Kivimaki M, Vahtera J, Virtanen M, Elovaino M, Pentti J, Ferrie JE. (2003) Temporary employment and risk of overall and cause specifi c mortality. Am J Epidemiol; 158: 663–68.
Lumsdon K. (1992) New surgical technologies reshape hospital strategies. Hospitals 66(9):30–33.
Marmot, M. et al., (2008) Closing the gap in a generation: health equity through action on the social determinates of health, Lancet 372:1661-1669.
Maxwell, R. J. (1984). Quality assessment in health. Br. Med. J., 288, 1470-1472.
Neely, A., Mills, J., Platts, K. and Richards, H. (2000), “Performance measurement system design: developing and testing a process-based approach”, International Journal of Operations &.
Norreklit, H. (2003) The balanced scorecard: What is the score? A rhetorical analysis of the balanced scorecard. Accounting, Organizations and Society 28(6): 591-619.
Ouchi, W. (1979), ‘A conceptual framework for Design of Organizational Control mechanisms’, Management Science, Vol. 25, No.9, pp. 833-48.
Reilly, G. P. and R. R. Reilly. (2000) Using a measure network to understand and deliver value. Journal of Cost Management: 5-14.
Rogers, A., Hassell, K., & Nicholaas, G. (1999). Demanding patients? Analysing the use of primary care. Oxford: Oxford University Press.
Schuster, M. A., McGlynn, E. A., & Brook, R. H. (1998). How good is the quality of health care in the United States? Milbank Q., 76, 517-563.
Steffen, G. E. (1988). Quality medical care: A definition. JAMA, 260, 56-61.
Tarlov, A. R., Ware, J. E., Greenfield, S., Nelson, E. C., Perrin, E., & Zubkof, M. (1989). The medical outcomes study: An application of methods for monitoring the results of medical care. JAMA, 262, 925-930.
Winefield, H. R., Murrell, T. G., & Cliford, J. (1995). Process and outcomes in general practice consultations: Problems in defining high quality care. Soc. Sci. Med., 41, 969-975.