Chief Executive Officer, The Cancer Council NSW
Four authors in this issue of Cancer Forum examine aspects of improving quality in cancer care.
Quality in health care is not unique in the diversity of terminology that divides its practitioners. The definition of quality, for instance, receives different treatment. The NSW Health Department, in its Framework for Managing the Quality of Health Services in NSW defines quality in health as doing the right thing, the first time, in the right way, at the right time1, leaving the definition of “the right thing”, or how it might be derived, an open question. Neither funders nor providers of health care would be satisfied with a quality objective constructed like that of the General Electric Company around “satisfying customer needs profitably”, notwithstanding that a greater emphasis on consumer perceptions is desirable. Wilson and Goldblatt2 encompass these perspectives in observing that “doing the right thing” involves four dimensions:
Defining technical quality has been at the heart of the program of the Australian Cancer Network in recent years, and in this edition, Abernethy, Phillips and Currow3 consider the process whereby evidence is compiled into guidelines, and the issues involved in translating these guidelines into practice policies that are implemented locally. This process of local adaptation has less formal treatment than upstream measures in evidence-based medicine, and this contribution is a welcome one. Health care professionals may be nervous about the emphasis on economic methods to define and evaluate trade-offs, but this is central to the value dimension of quality, and one where consumer participation to define acceptable trade-offs is essential.
The organisational environment in Australian health care is complex. The hospital, at least in the public system has been placed under financial pressures that have often been cost minimising rather than value optimising. At the same time, professional and organisational structures in hospitals have changed remarkably little, despite revolutions in technology and consumer expectations. (The industrial model of quality in contrast has involved fundamental re-engineering of organisations and production in order to take best advantage of new technology.) The anecdotal difficulties faced by health professionals in achieving effective change find some empirical support in the paper by Sorensen4 which highlights the barriers to managing quality that exist in the organisational environment surrounding a health care team. The centrepiece of her paper is the results of a survey of hospitals and health care staff undertaken by the Centre for Clinical Governance Research. It should be of concern that structures and practices to systematise clinical work appear rudimentary, and that quality opportunities appear to go begging. It underlines the need to reorganise for quality management, and the limitations of our current emphasis on qualifications, and audit of individual competence as ways of achieving quality.
These concerns unquestionably underlie the agenda of the Australian Council for Safety and Quality in Health Care (ACSQHC), outlined by Barraclough5, which was initiated in January 2000. Given its provenance in the Quality in Australian Health Care Study, the emphasis on adverse events is understandable, but as he acknowledges, there are several dimensions to quality.
Through its program of national standards, the ACSQHC may help to bridge some of the gap between the availability of evidence and guidelines, and the need for benchmarks that address translation into local practice. Ultimately quality is a health service level function, and there need to be local leadership and commitment to deliver effective outcomes. Indeed, the experience of improving cancer care relates to local and regional experiments. A 1998 US review could find no published data on attempts to improve an entire system of care6.
Multidisciplinary care is recognised in cancer to be an important, even a necessary precedent to quality, but how to implement this in all Australian health care environments, and avoid the cost impediments of some models is a challenge.
Quality management is a data intensive discipline. Deficiencies in data and in information systems in Australian health care are a major barrier to measuring the outcomes of care in the Australian population, and to determining the specific causes that underlie particular outcomes. The paper by Semmens, Fletcher and Brameld7 shows the power of record linkage databases in the assessment of outcomes in cancer care. They help answer the question whether the benefits of scientific and technical progress are being reflected in outcomes for the community. The great virtue of the Western Australian database is the speed and ease with which such studies can be performed to provide the loop closing step in the quality cycle. Surgical outcomes can presently be most efficiently measured in this way as procedures are better documented in routine hospital reporting.
With the ability to relate these results to the care received, it is feasible to more effectively associate outcomes with variations in practice, to identify quality problems, and to raise questions about the validity of practice policies that may be addressed by revision of clinical pathways, or by clinical trial. Improvements in recording of standardised data about the process of care are required together with the resources and systems required for supporting structured quality review, and quality problem identification at health service level. The use of limited sets of clinical indicators, separate from clinical pathways, as measures of quality in care is more problematic, especially when comparisons are made among institutions.
Survival analyses from state cancer registers compare Australian outcomes to overseas benchmarks. In these studies, Australia performs comparatively well. However, survival from cancer is but one yardstick of quality, and even it is affected by the quality underlying the benchmark. A recent US review, in generally the best performing jurisdiction on the survival scale, confirm that outcomes could be significantly improved there8.
Although there are other dimensions of quality, the papers in this issue deal mostly with the technical dimensions of quality. But, with long waiting times for treatment, it is possible that access to radiotherapy is currently the greatest quality issue facing the NSW Health system, while responsiveness and appropriateness are key consumer-focussed attributes. Although research, much of it Australian, has documented the extent of unmet supportive care needs among patients9, has researched and trialed efficacious measures to improve communication with and support for patients10,11, we are a way short of efforts to incorporate these systematically into cancer care. Although models of excellence proposed for cancer care in the United States attempt a consumer perspective6, expect it to be some time before communication skills rank alongside technical proficiency in credentialing criteria for clinical oncologists at Australian hospitals.
8. BE Hillner, TJ Smith, DE Desch. “Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care”. Journal Clinical Oncology 18, 11 (2000): 2327-40.
10. S Newell, RW Sanson-Fisher, A Girgis, A Bonaventura. “How well do medical oncologists’ perceptions reflect their patients’ reported physical and psychosocial problems? Data from five oncologists”. Cancer 83, 8 (1998): 1640-1651.