Specific quality elements in health care The provision of social and health services cannot be completely separated from each other. In the practice of providing social services, they intertwine and complement each other. When providing social services, the operators also perform some medical services. The Social Services Act allows facilities for the elderly, nursing care facilities, social service homes and specialized facilities to provide health services within the scope of nursing care, which some operators of these types of services also use. Others work with home nursing agencies (ADOS) to provide nursing care. However, there is also a whole range of other cooperation with healthcare services of the ambulatory or residential type. Therefore, it will be useful to describe at least the basic framework of the issue of quality from the point of view of healthcare.

The World Health Organization defined the quality of health care in 1966 as "the sum of the results achieved in prevention, diagnosis and treatment, determined by the needs of the population based on medical science and practice" (Weber in Madar, 2004). The definition from 1982 reads: "Quality health care is the degree of excellence of care provided in relation to the current level of knowledge and technological development and in accordance with economic possibilities." In the definition from 1999, quality health care is the highest attainable level of professionalism, with efficient use of resources, with minimal risk for the patient, resulting in a positive effect on health. Another definition of quality in health care is "the degree to which health services for individuals and populations increase the likelihood of desirable health outcomes and are consistent with current health knowledge." (Berwick, 2008) This definition provides several general themes:

  • Both - the population and the individual must be in balance when assessing the quality of health services.
  • "Health care services" refers to a wide range of services that affect health, including services aimed at disease prevention and health promotion, as well as acute services.
  • It is important to consider the patient's perspective (desired health outcomes).
  • The phrase "increasing the likelihood of desirable outcomes" reminds us that improving the quality of care does not equate directly to better health outcomes because there are other variables that have a large impact on outcomes. Poor results can occur even with the best possible care delivered (disease can eventually defeat even our best efforts). Conversely, patients can achieve good outcomes despite poor quality of health care. Quality assessment therefore requires attention to care procedures and outcomes.
  • High quality health services are about making the best use of current knowledge - make sure that doctors are always up to date and that they actually use the knowledge.

Table 1: The Institute of Medicine presents 6 dimensions of quality.

Table 1Download Excel
Safe care Avoid injuring or harming patients in care that aims to help them.
Patient-centered care Providing care that respects and responds to the preferences, needs and values ​​of individual patients and ensures that the patient's values ​​guide all clinical decisions. It refers to healthcare that establishes a partnership between professionals, patients and their families, and that patients have the education and support they need to make decisions and participate in their care.
Effective care Avoid waste, including waste, equipment, supplies, ideas and energy.
Appropriate care Reducing waiting and sometimes harmful delays for both those receiving and providing care.
Fair Care Providing care that should not differ in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.
Clinically effective care Providing science-based services to all who might benefit, and refraining from providing services to those who do not (avoid under- or over-care, respectively)

Source: Quality Improvement Strategic Plan 2008 – 2011. Counties Manukau.

The Slovak Republic had an approved National Quality Program for 2008-2012, in which the issue of quality in the healthcare sector was included in the point "Care for health". The global goal in this area was "to improve the conditions affecting the health status of the population in both productive and non-productive age by increasing the quality of health care" (NPK 2008-2012, p. 5). He set himself strategic goals:

  1. ensure prevention and availability of health care for all social and age groups of the population,
  2. support organizations in the implementation of the OHSAS 18 001 standard,
  3. increase the quality of care for the client - patient,
  4. improve the quality of treatment according to international protocols and guidelines,
  5. ensure the prevention of risks, injuries and negative manifestations,
  6. metrological assurance of medical devices and equipment,
  7. create and implement relevant national standards within the quality management system of provided health care services.

In 2013, the National Quality Program of the Slovak Republic for the years 2013-2016 was adopted, where Health care, they set the following goals:

  • improving the quality of life in the field of public health,
  • strengthening the health awareness of SR citizens,
  • strengthening the participation and rights of patients in the health care process,
  • accreditation and certification in the field of healthcare as a tool for proving the professional competence of subjects,
  • improvement of drug policy with regard to the patient,
  • initiating health care and recommending a healthy lifestyle
  • application of a systemic approach to quality management (ISO, EFQM excellence model)

What quality is specifically can be defined for us by many different subjective opinions as well as objective evidence. Concepts such as quality of life, quality of the environment, quality of product, quality of nursing actions, quality of managerial activities, quality of structure, quality of results and quality of processes signal to us the idea of ​​a measure of quality. In a business environment, quality must be clearly explained so that the quality process can be managed and goal-oriented. This also applies to quality management in health services.

Health services, like social services, mostly have an intangible product. It is an activity that takes place between the client - the patient and the provider. Nursing activities, as well as social services, are characterized by the presence of the patient directly in the main process. The focus is always on frontline workers (doctors, nurses, paramedics) and they have a better opportunity to respond more flexibly to the wishes of their clients. The quality of health care is defined by Donabedian as "the kind of care in which the maximum benefit for the patient's health can be expected, and when the expected benefit is higher compared to the costs in all phases of the treatment process" (Gladkij in Madar, 2004).

The quality of provided health services is a topic that is not only of interest to the operators of health facilities, but also to the state administration, health insurance companies, the general public - such as health insurance payers, patients and, in the context of our topic, also those operators of social services who deal with quality improvement in their facilities and provide or ensure nursing services. In order to correctly describe the relationship between the quality of services and health care, we first provide the definition of health care, which is given in § 1 par. 1 of Act no. 576/2004 Coll. on health care, services related to the provision of health care and on the amendment of certain laws: "Health care is a set of work activities performed by health workers, including the provision of medicines, medical aids and dietetic foods with the aim of prolonging the life of a physical person, increasing the quality of his life and the healthy development of future generations; health care includes prevention, dispensary, diagnosis, treatment, biomedical research, nursing care and midwifery assistance." When evaluating the quality of health care, we also evaluate health performance, which should be a fundamental consideration in the perception of the quality of health care. "Medical performance is a comprehensive activity of a health worker, which represents the basic unit of providing health care". Support services that accompany the patient also play a significant role. In our case, the functional connection and cooperation between the nursing, nursing and physiotherapy components of the service is crucial.

It is important to set limits and standards for quality management. The following types of standards are mostly used in practice (Gladkij, 2003, p. 280-281):

  • Work consumption standards (number of occupied beds per 1 nurse, average length of treatment time);
  • Physical standards (fuel consumption per 100 km driven, consumption of material for treating pressure ulcers);
  • Capacity standards (average percentage of beds occupied, bed downtime after each discharge);
  • Cost standards (material operational costs for 1 treatment day, health care costs for 1 patient, drug costs for 1 patient);
  • Capital standards (refer to invested funds and their payback period, ratio of current assets and liabilities, ratio of debts and net assets, etc.);
  • Income standards (relate to income for the sale of services - income per health worker, income per 1 patient, income per procedure or diagnosis);
  • Program standards (they can relate to various aspects of the activity, e.g. reducing the level of lethality by a certain percentage, increasing the average life expectancy in a certain period, carrying out a certain screening action, introducing a new technology);
  • Non-quantifiable standards (refer to such problems as, for example, improving the level of nursing care or increasing client satisfaction with services, improving the level of management, improving the level of interpersonal relations at the workplace.

The quality system in healthcare can be defined as a summary of the structure of the organization, individual responsibilities, procedures, processes and resources that are necessary for continuous improvement of the quality of healthcare services. Their ultimate goal is to improve the health status, increase the quality of life and the satisfaction of the residents who receive care. The quality system thus includes the entire process of creating procedures, collecting information, setting standards and evaluating the results of what we organize in the healthcare sector as healthcare and healthcare services. (Gladky, 2003)

In connection with the growth of expenditures on health care, with the development of new medical technologies, questions related to the evaluation of the results and contribution of health care to population health are increasingly coming to the fore. We cannot evaluate the level of health care only according to the level of inputs available to the health care system, nor according to the processes, but the result is decisive. According to Ozorovský (2011), it is necessary to measure the results of health services in general based on the following characteristics:

  • early discovery of a health condition disorder,
  • averting the disease, reducing the consequences for the patient,
  • averting or delaying death,
  • shortening the duration of treatment,
  • complete healing of the patient or substantial improvement of his health condition, improvement of his quality of life.

The goal of quality management systems is to improve the quality of care provided in accordance with the needs and requirements of patients and external and internal clients. The aim of quality improvement is also to limit errors, undesirable results, wasted time and added costs associated with poor quality of a specific health care performance or service. The Slovak Republic can also use international standards. For example, the Joint Commission International published the International Accreditation Standards for Hospitals (2008). In the first part, patient-oriented standards are listed:

  • availability and continuity of care.
  • the rights of patients and their loved ones.
  • diagnostic and therapeutic care.
  • anesthetic and surgical care.
  • storage, prescription and administration of medicines.
  • education of patients and their loved ones.

The second part describes the standards aimed at hospitals:

  • quality of care and patient safety.
  • prevention and control of nosocomial and professional infections.
  • management and leadership.
  • ensuring the safety of the hospital environment.
  • qualification and training of personnel.
  • information and communication management.

Jakušová (2010) presents the division of the quality dimension in healthcare as follows:

  • the quality of services from the patient's point of view expresses what the patient expects from the services.
  • the quality of services from a professional point of view explains whether the services provided are of a professional nature.
  • the quality of services from the point of view of management expresses the most efficient use of resources within the limits and directives of superiors.

Author: PhDr. Mária Kovaľová, PhD., MHA Tabita s.r.o. and the Institute for the Quality of Social Services http://www.tabitasro.sk

BERWICK, D. Quality Improvement Strategic Plan 2008 – 2011, Improvement, Trust and the Healthcare Workforce by Don Berwick., ISBN No. 978 – 0- 9582961-1-3 GLADKIJ, I. et al 2003. Management in health care. Brno: Computer Press, 2003. 380 p. ISBN 80-7226-996-8. JAKUŠOVÁ, V. 2010. Basics of health management. Martin: Osveta, 2010. 142p. ISBN 978-80-8063-347-9. MADAR et al. 2004. Quality management in a healthcare facility. Prague: Grada Publishing, 2004. 248 p. ISBN 80-247-0585-0. OZOROVSKÝ, V. et al 2011. Social medicine. Bratislava: Asklepios, 2011. 166 p. ISBN 978-80-7167-158-9.

Documents: National quality program of the Slovak Republic 2008-2012 National quality program of the Slovak Republic 2013 - 2016 The Joint Commission International published the International Accreditation Standards for Hospitals (2008). Act of the NR SR no. 576/2004 Coll. on health care, services related to the provision of health care and on the amendment of certain laws as amended.