Introduction
Improving healthcare is a goal across the world. In order to reach this goal, it is necessary to develop criteria, indicators and instruments to assess quality. Nearly fifty years ago, Sanazaro and Williamson noticed that not much work had focused on the development of objective criteria of performance (Donabedian 1966). For this reason, they conducted a study to create a classification—based on episodes of care provided by physicians—of what constitutes effective and ineffective performance (Sanazaro and Williamson 1970).
Since that time, a vast amount of literature has been published to understand better what quality care is and to find the most appropriate criteria and tools for its measurement and improvement (Arah et al. 2006; Brook et al. 1996; Campbell et al. 2000; Donabedian 1988, 1990; Institute of Medicine 2001; World Health Organization 2006). Major trends that have originated in the management field—such as Total Quality Management, Quality Assurance, Continuous Quality Improvement, Lean or Six Sigma—have also been applied to healthcare. In addition, publications such as those from the Institute of Medicine 1999, 2001), and associations such as the Joint Commission International, the American Society for Quality, the National Association for Healthcare Quality, the International Society for Quality in Health Care and the Agency for Healthcare Research and Quality have emphasized quality problems and their improvement.
Given this ‘quality revolution’ (Maguard 2006), we replicated Sanazaro and Williamson’s (1970) design about fifty years later, using a sample of healthcare managers, to compare our results to their suggested classification, identifying differences and similarities between physician and managerial perspectives and discussing the evolution of quality dimensions over time.
Methods
This study is part of a larger project (Amati et al. in preparation) to develop an empirically informed taxonomy of quality of care, grounded in Donabedian’s structure, process and outcome framework (Donabedian 1996, 1998). We refer to that paper (Amati et al. in preparation) for a more detailed description of the methods used.
We replicated a revised version of the critical incidents technique adopted by Sanazaro and Williamson (1970), who collected 9115 episodes of patient care —describing effective and ineffective performance—from 2342 physicians. Our sample comprised 236 top managers in executive positions, middle managers and directors, who had completed the Masters of Science in Healthcare Administration programme at Trinity University (San Antonio, Texas) from 2004 to 2013.
Sanazaro and Williamson’s (1970) classification system first divided quality statements into process (i.e. what physicians do to patients) and outcome (i.e. effects of physicians’ performance on patients). In addition, they identified specific subcategories of both process and outcome, such as ‘arriving at diagnosis’ or ‘improvement of physical abnormalities’.
Each episode of care from our study was analyzed using this classification, in order to ensure a comparison of the data. Moreover, we used an inductive exploratory approach to examine those parts of the texts that did not belong to any of Sanazaro and Williamson’s subcategories, leading to the identification of new dimensions of quality care (Amati et al. in preparation). Finally, after the percentages for each subcategory were calculated, we modified three tables published in Sanazaro and Williamson’s (1970) work to compare our results to theirs. The comparison was made by looking at ranks and means and did not use formal statistical analysis.
Results
Sample Characteristics
A total of 135 episodes of care were collected from 74 managers (response rate = 33%). Fifty-three percent of the respondents were female and the average age was 35 years old, with a mean of eight years of experience in healthcare management. Professional titles ranged from ‘Executive/Vice President’ (24%) and ‘Director/Manager’ (32%) to ‘Assistant/Associate Administrator’ (16%) and others, such as ‘Consultant’ and ‘Analyst’. Concerning organizational settings, 56% of the respondents worked in private not-for-profit hospitals, 19% in public hospitals, 17% in private for-profit hospitals, whilst the rest worked in other types of healthcare organizations (e.g. health insurance companies or outpatient clinics).
Process Subcategories
Sanazaro and Williamson’s Subcategories
Table 1.1 reports the top fifteen process subcategories of effective and ineffective performance most frequently reported in this investigation, compared with those from the original work (Sanazaro and Williamson 1970). Overall, Sanazaro and Williamson’s (1970) process subcategories were replicated by our data. However, the ranking and percentages were quite different from the original study. Since Sanazaro and Williamson’s (1970) investigation used physicians to describe quality of care, their derived taxonomy was very detailed about certain elements of the delivery of care (e.g. use of instruments, X-ray, EKG, caesarean section , etc.), which were not as prominent in our study.
Table 1.1
The top fifteen process subcategories of effective and ineffective performance most frequently reported by the healthcare managers in our study in comparison to Sanazaro and Williamson’s study (1970), expressed in percent
Sanazaro and Williamson (1970) | Our study (2017) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Effective | Ineffective | Effective | Ineffective | ||||||||||
Ranking | Internal med (N = 8521) | Surgery (N = 4100) | Paediatrics (N = 3479) | OBGYN (N = 2166) | Internal med (N = 4059) | Surgery (N = 2272) | Paediatrics (N = 1777) | OBGYN (N = 1221) | Total (N = 333) | Total (N = 229) | |||
1 | Arriving at diagnosis | 11.7% | 11% | 11.3% | 10.5% | 12.4% | 8.9% | 12.8% | 8.7% | Use of health team | 13.8% | Staff-patient-family comm.* | 15.3% |
2 | Drugs, biologicals, etc. | 9 | 4 | 8.6 | 6.1 | 11.6 | 3.2 | 10.5 | 7.5 | Staff-patient-family comm.* | 12.4 | Timeliness* | 10.5 |
3 | Patient education | 6.6 | 7.4 | 8.2 | 9.9 | 5.6 | 6.7 | 7.8 | – | Timeliness* | 9.3 | Inter-staff comm.* | 9.2 |
4 | Laboratory | 5.8 | – | 6 | – | 4.3 | – | 5.4 | – | Patient-centredness* | 6.3 | Use of health team | 8.3 |
5 | Use of facilities | 5.3 | 3.2 | 6.4 | 3.8 | 3.7 | – | – | – | Inter-staff comm.* | 5.4 | Professional manner | 7.9 |
6 | General evaluation | 5.3 | 4.3 | – | – | 4.5 | 3.3 | – | – | Surgical treatment | 5.4 | Adherence to guidelines* | 7.9 |
7 | Surgical treatment | 5.3 | 22.3 | 4.5 | 12.6 | – | 26.1 | – | 13.5 | Use of facilities | 4.5 | Physician availability | 4.8 |
8 | X-ray | 5 | 4.6 | 7.5 | 5.8 | – | – | 4.5 | 4.8 | Professional manner | 4.5 | Professional responsibility | 4.8 |
9 | Physical examination | 5 | 4.6 | 7.5 | 5.8 | – | – | 4.5 | 4.8 | Patient education | 4.5 | Patient education | 4.4 |
10 | Consultation | 4.5 | 3.4 | 6.2 | 3.9 | 4.6 | 4.8 | 4.5 | 3.5 | Arriving at diagnosis | 3.6 | Surgical treatment | 3.9 |
11 | Profess... | ||||||||||||