Performance in the health care sector is now a priority and in all cases, this performance must be evaluated. Financial measuring tools have always been used to measure performance but we need to think beyond finances. For this reason, quality concepts are developed to measure performance rather than the use of financial bases only. Avenis Donabedian who was a renowned physician developed a model for measuring the quality of health care. It is a structured process outcome model. This implies that the model defines the surroundings in which the health care is given, the method of providing the health care, and the results as-either benefits or consequences of providing the health care. These three stand for the structure, process, and outcome respectively and this is the main reason why the model is referred to as the structure process outcome model. So how is this model applied in health care? And how does it compare with other theories? How does its knowledge assist in the improvement of the quality and the organization of a health care unit? (Degeyndt, 56-98)
In the introduction, I have explained that the structure describes the environment in which health care is given. In this area, we find all apparatus and resources that are available for the workers and administration in the health care facility. It will also include the qualifications of the personnel, the organization, and even the structures or the buildings available which will fall under the capacity of the health care facility. In brief, the structure can be categorized into a physical structure, financial structure, and organizational structure. (Degeyndt, 56-98)
Process measures of quality will describe things done to and for the patient during the time of treatment. It highlights any problems and difficulties interfering with the provision of health services. Here we find things like surgical operations, prescriptions, screening, analysis, follow-up of the patient, real treatment, and even primary prevention. (Batalden et, el 115-178)
Outcome measures are the results after the care has been given. Things like the reduction of morbidity and death rates and also better quality of life. Donabedian presents two types of outcomes: Technical outcomes and interpersonal outcomes. Technical outcomes include the bodily and useful aspects of care. It encompasses such things as the absence of complications after any surgical operation, successful control of heart diseases and complications, and even management of all other chronic conditions like cancer and diabetes. Interpersonal outcomes will include the psychological satisfaction of the patient that he or she has received the best health care and that he is doing well. The two outcomes depend on each other and according to Donabedian; you can’t achieve one outcome without involving the other. (Batalden et, el 115-178)
The three aspects are also dependant upon one another according to Donabedian. There is a link joining the three aspects. Good structure leads to a good process, the good process leads to good and favorable outcomes, and good outcomes go back to improve the structures and the processes. Outcomes are quantified by aspects like morbidity, mortality levels, and psychological aspects of the patient after treatment. The above ways are essential and assist to improve the health care system. However, determining the indicators is not a simple business. It is not easy to measure the right performance aspects. It takes a lot of research to identify the right methods of effective care. The quantities of structure may be measured easily, the quantities of the process can also be determined, but the outcome aspect which is more of a psychological aspect of the model may not be measured. Even if the patients give some responses through questionnaires, they may sometimes exaggerate the responses to suit their interests.
Research on the effects of these aspects describes how the health care organization operates appropriately. Indicators are going to be discovered in the process which will eventually be applied in improving the quality of health care. For example, research to determine ways of improving the structure which we said describes the environment where the health care is given including the performance of the physician found out that increasing the length of training, encouraging specialization in one area, which the physician has trained for, and further studies on the area of specialization are some of the things that can improve the structure of a health care unit. An organization that wants to do well in this area of structure should apply these methods to improve the performance of the health care unit. Since the three are interdependent if the structure improves the other two will also improve automatically. Large group practices will also improve the structure by ensuring that a physician specializes in his area and also observes the protocols of operation. By working in groups, one has a manageable workload and this renders him more effective in his duty. The model is offering a methodology to study or even come up with indicators for improved health care. (Langley, 15-45)
The size of the unit will also affect the performance of a health care organization. A large-sized unit will report fewer deaths as compared to small-sized units. In addition to this, a unit with many physicians will also have a low mortality rate compared to one with very little personnel. A health unit wishing to improve its structure will consider these indicators to improve its performance. (Langley, 15-45)
Some other indicators that affect the structure of a health care unit include; cleanliness, safe water, air, good management, and provision of the appropriate goods and services like medicine. These have been measured through research and they are appropriate indicators of performance. (Batalden, 424-470.)
If a health care organization has these ways in mind and uses them appropriately, the quality of health care will be improved. When this model is used, the management will be able to know through these indicators where to make changes to improve the services. For example, the indicators may imply that a change is required in the staffing system, or in the way the organization is arranged, or even in the physical structures like the buildings. A good management system will make these changes and do any other thing which is indicated by those indicators in question. (Degeyndt, 56-98)
So how is this model related to the contingency theory? The contingency theory states that the outcomes of an organization are determined by the relations of the main elements of an organizational structure and how it operates. The theory argues that there is no one good way of managing or structuring an organization and that what is needed is to support the functions of the system through appropriate structures. It differs from the structure process outcome model in the sense that it includes in the structure issues of choice of mechanisms from the organization that will improve the exchange of information, harmonization, and incorporation of effort across the health care unit. These issues include; formalization which catches the issue of records in the organization, specialization which refers to the degree of sharing roles in the organization, standardization which is the degree of consistency in operations of the organization, complexity which is the number of units in the organization and finally centralization which refers to the exertion of authority in the organization. The structure process outcome theorists use indicators of organizational capacity and ability while the contingency theorists focus on the methods to improve communication, harmonization, and organization. The two might be different in the view of their structures but they eventually lead to the same outcomes if utilized effectively. (Donabedian, 15-45)
Their main purpose is to indicate ways of improving quality health care. The effects of the application of the two theories after research carry so many things in common. We have earlier discussed the aspects that could bring improvement in a health care organization under the structure process outcome model. Similarly, there are some aspects of the contingency theory which explain the improvement of the organization. For example, the type of communication and control systems applied will affect the outcomes of the organization. Some forms of communication will lead to increase mortality rates while others will lead to decreased mortality rates. Application of the contingency measures discussed earlier leads to decreased rate of mortality. If the measures were not applied positively, then the opposite which is increased mortality rates would be the outcome. (Langley, 15-45)
The application of these theories and other ethical requirements in health care leads to improved performance in health care organizational units. One of these activities that can assist in the improvement is record keeping in health care organizations. There has been a traditional belief among the old physicians that it is impossible to trust the public with details about the findings of a certain treatment. This is not a topic of controversy. The issue here is that whether the information will be concealed or not, it has to be recorded. The purpose of recording is summarized by three functions; One, for scientific studies which may be done by any professional on the procedures and results. Second, for practical purposes, for instance in a case where the patient returns to the hospital after some time, and lastly for medico-legal purposes where the law dictates records for special cases like accidents. These are obvious reasons and many have complied.
Apart from the above reasons is another one which is a core function if quality health care will be provided. The data kept will be used to increase the efficiency of the health care unit. It is very appropriate for a record to be kept showing what the doctor did to the patient, the results, the nature of the result, the reason for that result, and faults done by the doctor or the patient if any. This is an essential aspect in providing quality health care and should be practiced by all hospitals whether big or small. (Senge, 189-198)
A quality process of care is associated with good structures. A health care unit should ensure that all the structures as discussed above are improved in a positive direction. This will in turn lead to a good process for the patient and eventually some good outcomes. Avenis Donabedian provides a model to improve the quality of health care. It is not absolute in itself and other theories like the contingency theory as discussed above will also be effective when applied. (Batalden et, el 115-178)
Batalden, Stoltz. “A framework for the continual improvement of health Care”. J7oint Commission Journal of Quality Improvement. 1993; 19: 424-470.
Degeyndt, Willy, “Managing the quality of health care in developing countries.” P. Cm-World bank technical paper No; 258. 1995. 56-98
Donabedian, Avenis. “Aspects of Medical Care Administration: Specifying Requirements for Health Care”. Cambridge: Harvard University Press, 1973, 649-670..
Langley, Nolan, Nolan. “The founidation of improvement.” Silver Spring, MD: API Publishing, 1992. 15-45.
Senge, Peter. “The fifth discipline: the art and practice of the learsing organization”. New York: Doubleday/Currency, 1980. 189-198
Watzlawick, Weakland, Fisch. “Change: principles of problem formulation and problem resolution”. New York: WWNorton, 1974. 115-178.