Services provided by a hospital incorporate elements which can be examined objectively, subjectively or both. Every enterprise is actively concerned with quality assurance by determining the quality of the commodity it produces and keeping in touch with consumers to secure their maximum satisfaction.
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As a result of advances in medical technology, introduction of complex diagnostic and therapeutic procedures, introduction of high technology and other sophisticated elements, some vital issues are being raised, such as: what is the quantum of output and degree of excellence of hospital service?
What is the cost of operating the hospital? Is the hospital spending more because of inefficiency of hospital operation? Could the same quality of medical care be made available at lesser costs?
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What is the extent of patients’ satisfaction? What are the final outcome or end results in terms of indices like recovery rate, partial recovery rate, death rate, complication rate, etc.?
However, due to the diverse nature of activities, large number of variables and subjectivity, results is difficult to measure in hospital services.
By its very nature, a great part of hospital output will always be intangible.
Therefore, the measurement of tangible and intangible outcomes must go hand in hand, and no watertight compartmentalization can be made between them. Because of this the evaluation process has greatly depended upon qualitative judgments in addition to quantified data in most instances.
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Evaluation of hospitals is a challenge because of the variation in the intensity of care, equipment, personnel, and facilities in different types of hospitals.
One cannot be sure that the instruments of evaluating the services in hospitals could be made as sensitive, valid, accurate and specific as one finds in industry where accomplishments can be measured in terms of an accountable unit, viz., rupees and entirely by financial tools like profit and loss statement and balance sheet.
Because of this multidisciplinary nature, medical care in hospitals does not lend itself to simple and direct units of measurement. What one can measure are therefore certain components or characteristics of it from which one can draw inferences and implications.
Evaluation of Hospital Services:
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The last stage in the management process, viz. evaluation is designed to measure the efficiency and effectiveness of the services after planning, organising, directing and controlling.
No organisation worth its name can survive and progress unless it overcomes its shortcomings and builds upon its past performance. One cannot substitute form for substance and appearances for reality for all the time.
Sophisticated technology in high-tech hospitals is equated with high quality care in the minds of both public and the providers, and high costs and quality are considered synonymous. Nothing can be farther from the truth.
Considered from all aspects, there are three main reasons which warrant objective evaluation of hospitals.
1. It is to safeguard interests of the recipients of hospital care. A layman cannot possibly judge for himself whether the care he is receiving is judicious and scientific.
He has insufficient protection against malpractices, exploitation and inefficiencies of hospital’s medical staff and systems. Hence, it is the moral and legal obligation of the administrative and professional authorities to ensure that hospitals render safe and efficient medical services to patients.
Besides, the legal accountability of the hospitals also cannot be overlooked.
2. It is to locate inadequacies and shortcomings of the hospital staff, its plant and machinery and what is most important, it’s working systems. Apparently, the hospitals’ end results cannot be good if there are no proper facilities or appropriate technical environment in which the physicians can work.
3. It is to provide the authorities, viz. governing body, board of trustees or owners a sound appraisal system of the effectiveness of managerial staff at various levels, hospital administrators and individual physicians, and furnish valid facts and data to regulate their future development.
Productivity is the relationship between resources used and results produced, i.e. the input-output ratio. A periodic assessment of the services will show the existing state of affairs, and therefore scope for corrective action for quality assurance.
Quality assurance aims at establishing a programme for monitoring and evaluating the quality of care, but is not synonymous with use of sophisticated procedures and invasive technology. It entails a cost-effective approach for optimum utilisation of resources and establishing ongoing quality control programme.
What is Evaluation?
Evaluation has been defined as the process of determining the degree of success in achieving predetermined objectives it is also defined as “Measurement of action against accepted criteria and interpretation of relationship amongst them”.
Appraisal, assessment, progress reporting, progress assessment, and review and analysis are some of the terms which have been used synonymously with evaluation.
What to Evaluate?
In hospitals and health care, there are five indicators through which the quality of medical care and services can be assessed.
1. The organisation
2. The process
3. The content
4. The outcome
5. The impact.
Traditionally, these can be grouped into three categories, viz. the means (structural factors), the methods (process factors), and the end results (outcome factors).
Evaluation of the “Means”:
Evaluation of the “means” covers the inputs, ascertaining whether the hospital has been provided with optimum quantity and right quality of staff and physical facilities as in the shape of buildings, equipment, drugs, diet and supplies.
Evidently, if the means are inadequate, the quality of hospital services would be of a low standard. Basically, this is an evaluation of the “organisation”.
The inputs that go into the production of medical care are the men (various categories of personnel), money, materials and machines. Effective utilisation of these resources determines the organization’s effectiveness.
The quality assurance committee has to ensure that there has to be a basic minimum infrastructure regarding space, equipment, physical facilities and the staff requirement.
The type of organisation needed for each department or service, that is the authority-responsibility relationship, coordination and the budget has to be tailored to the need of each department keeping in view the overall hospital objectives.
Evaluation of the “Methods”:
Evaluation of the methods is determining whether there is an effective utilisation of the available human and material resources and whether the hospital’s policies and working procedures are sound and judicious.
Understandably, if the hospital’s functioning and administration is poor, then the quality of its care cannot be of a good standard. This is an evaluation of “process” and “content” of the hospital care.
The quality assurance committee lays down the standing instructions for various procedures, patient documentation, and other records. The evaluation is carried out through many standing subcommittees like tissue, utilisation, therapeutic, nursing and infection control.
Evaluation of the “End-results”:
Evaluation of the “end-results” means judging the effectiveness or ultimate outcome of the benefits derived by individual patient and the community from the hospital. This is an evaluation of the “outcome” and “impact”.
Evaluation studies of each of the above five aspects of a hospital’s operations, i.e. the organisation, process, content, outcome and impact can be a very complex process.
For example, the evaluation of organisation and process requires detail analysis with the help of operations research techniques and quantitative methods. On the other hand, a lot of subjectivity is involved in evaluating the range, quality and quantity of services provided by the hospital.
It is not always possible, or even necessary, that evaluation of all the above should be carried out simultaneously, although the need for such simultaneous evaluation is apparent in the overall context.
But since the objectives, and derivative objectives of hospitals are not available in clear terms, sometimes what is only possible is evaluation of output—both in terms of qualitative and quantitative determinants, and evaluation in terms of cost and utilisation.
Difficulty with Outputs:
Nevertheless, a hospital does not have just one output. A medical ward may “produce” deaths and discharges and occupied bed days; the hospital laboratory may produce different types of investigations unrelated to each other in their complexity and cost, the OPD “produces” outpatients treated, and so on.
Thus, many different types of outputs are involved and each must be matched to the appropriate input(s).
Then, some outputs may be ends in themselves, and others the means to an end. A hospital is not primarily an institution to produce meals, nevertheless meals prepared per cook or distributed per catering assistant is as valid a measure of catering performance as admissions per bed is of overall hospital performance.
All outputs must be measurable but unfortunately, many cannot be precisely measured.
Therefore, in the hospital evaluation will contain many performance measures which are qualitative; it will also contain other ratios which may not measure performance but which only help to explain levels of performance.
Steps in evaluation:
There are five steps in the process of evaluation.
Step-I: Definition of the Purpose and Scope of Evaluation:
In step I, the scope will have to be stated in such terms like whether it will be with reference to technical considerations, administrative considerations, consideration of effectiveness or efficiency, or a combination of one or more of them.
Step-ll: Detailed Description of the Hospital System and Its Operation:
One needs to clarify and define the objectives of the hospital in as specific terms as possible, the steps, activities and
procedures that are carried out, the details of administrative machinery that performs the various activities and the cost of all these activities.
Step-lll: Determination of Indices and Criteria for Measuring the Achievement of Objectives:
An index is an instrument or measuring device which measures on a sliding scale the achievement of a particular objective or set of objectives, whereas criterion is the particular value, on the measuring scale which defines success or failure in absolute terms.
For proper measurement, any index should have the following three important characteristics.
1. It should be specific
2. It should be sensitive
3. It should be reliable.
An important step in evaluation is to prescribe the standards of what we shall accept as satisfactory performance. Evaluation has no meaning unless we establish some yardsticks and formulate means, by which one thing can be compared with another.
For that we must first determine all possible characteristics and components of technical and administrative services.
Thereafter, we should consider what should be the desired “level” or “par” of each characteristic. This is generally the most difficult part in evaluation of hospital services.
The five basic aspects involved in hospital operations are facilities, personnel, procedures, organisation and professional management. Standards to be achieved, or desired, will have to be developed for each of these aspects.
Leaving aside the crucial aspects of accuracy of hospital data, there are no recognised benchmarks against which objective judgments can be made.
Whether a high bed turnover rate is good or bad will depend on local circumstances, because hospitals within a given classification vary widely in size, location, design, resources and skill.
Despite attempts to “standardise” hospital characteristics, it will always be impossible to ensure that like is being compared with like.
And, interhospital comparisons must be interpreted with considerable caution.
Performance indicators are only indicators and not measures of performance: It needs to be emphasised that in India we do not have universally accepted norms on any aspects of hospital performance.
Therefore, application of specific figures to any individual hospital must be as a guide only, with interpretative understanding of conditions within that hospital.
Simple indices can be misleading, and sophisticated analysis has limited impact. Higher or lower figures than average or generally acceptable standards do not necessarily mean worse or better hospital services.
They mean attention is called to a situation which differs only from the usual norm, and which may or may not be fully justified, but, in any event, should be explained.
Thus, administrators are led to investigate problems highlighted by performance indicators at the work areas by talking to the people involved.
Step-IV: Preparing and Execution of Evaluation:
Plan and design of the study will now have to be prepared and executed utilising the various methods such as, observations, interviews, study of documents and records.
Step-V: Reporting the Results of Evaluation:
In step-V, the reports will include broad facts of the study and conclusions reached. Recommendation if required could also be submitted, with suggestions regarding alternative courses of action and modification in the present procedures.