Quality Improvement of Healthcare
Healthcare is complex and comes with great cost for many people. In time, changes have been proposed to attempt to improve healthcare deficiencies. Although the healthcare system is not perfect, there is always room for quality improvement in healthcare as it is continuously changing. History, current framework and characteristics, healthcare disparities and future solutions are all important factors that impact the constant change in quality improvement in healthcare.
The history of healthcare is extremely important and valuable. The healthcare delivery system evolved in the 1800’s. In the mid 1800’s the first hospitals were founded by New Orleans, Philadelphia and New York, and the first medical schools had opened. The first hospital was opened in New Orleans, which was the Royal Hospital, but was too expensive for most people to use its services, so a second hospital was built (Shi & Singh, 2017, p. 55-56). The healthcare system has grown tremendously since the first hospitals and medical schools were opened. Historical factors, historical periods and discoveries, as well as understanding the importance of the history of healthcare are all important to understand the current healthcare system as it is complex, and continually changing.
Some historical factors include, beliefs and values and the founding of Medicare and Medicaid. Beliefs and values such as capitalism, self-reliance, and limited government have been responsible for shielding the U.S health care system from a major overhaul (Shi & Singh, 2017, p. 54). In addition to beliefs and values having a historical impact, Medicare and Medicaid which was enacted by President Lyndon Johnson (“The Social Security Amendments of 1965 established Medicare and Medicaid in the United States”) (Rajaram & Bilimoria, 2015, pp. 1) has had an enormous impact on the health care system continuously as it effects so many people.
Medicare and Medicaid are examples of social and political factors that have led to the creation of programs to accommodate certain defined groups of people (Shi & Singh, 2017, p. 54). Both Medicare and Medicaid are government-funded programs funded to help those due to age, income status, or disability (Marjoua & Bozic, 2016, p. 266). In 2017 it was reported that around 57 million individuals were enrolled in Medicare, 33% were enrolled in the standard Medicare advantage plan (Medicare Advantage, 2017, pp. 2). The current total of individuals enrolled in Medicaid services is nearly 73.6 million (Medicaid.gov, 2018, pp. 3). For some individuals both Medicare and Medicaid may be combined to help those enrolled in Medicare who may need additional financial help (Rajaram & Bilimoria, 2015, pp. 1). The combination of Medicare and Medicaid allows for Medicaid to pick up the remaining cost that Medicare does not cover to keep the patients’ costs lower. Both programs are extremely important in helping ensure patients have proper medical care.
There are four recognizable historical periods in which major changes in the structure of the medical delivery system are categorized under. The historical periods that have had factors that have contributed and continue to contribute to shaping the U.S health care system are: the preindustrial era, postindustrial era, corporate era, and the health care reform era (Shi & Singh, 2017, p. 55). The preindustrial era begins from colonial times to the late 1800’s. Great Britain, France and Germany were far more advanced in medical education and practice. Practice in the United States was not as strong professional due to medical procedures being primitive (Shi & Singh, 2017, p. 55). The postindustrial era according to the Shi & Singh (2017) was marked by growth and development of a medical profession that benefited from urbanization, which included new discoveries and reforms in medical education (Shi & Singh, 2017, p. 59). A few other notable developments during the postindustrial era were: hospitals became true medical care institutions, growth of private health insurance, and the creation of Medicare and Medicaid (Shi & Singh, 2017, p. 59).
The corporate era was in the later part of the 20th century and the beginning of the 21st century which have been marked by growth and consolidation of large business corporations and advances in trade, transportation and global communication (Shi & Singh, 2017, p. 72).
The era of health care reform “refers to major changes undertaken by the government to expand health insurance to the uninsured and regulate the financing and delivery of health care (Shi & Singh, 2017, p. 74). All eras, the preindustrial, postindustrial, corporate and health care reform have all introduced and developed new advances in health care, which contribute to growth in the U.S health care delivery system.
“The system’s historical foundations explain why a government-run national health care system has not materialized in the United States”, is an example of the importance of understanding the history of the healthcare system (Shi & Singh, 2017, p. 53). Understanding the health care delivery system today it is important to understand the background and history of the health care delivery system.
Understanding the framework and characteristics of healthcare are essential in showing how to improve and maintain the system. The systems framework is an outline of the many different components that make up the U.S. health care delivery system (Shi & Singh, 2017, p. 12). The systems framework provides an understanding of the United States health care delivery system by organizing the various main components in a logical way. The systems framework demonstrates the progress from inputs to outputs. The five main elements of the systems framework are: system structure, system resources, system processes, system outcomes, and system outlook (Shi & Singh, 2017, p. 9). The framework plays a large role in forming a great health care system. System structure is defined as the factors that form ideas behind the individual health care organizations (Piña et al, 2015, p. 672). System structure is the foundation of the framework. In their journal Piña et al. (2015) states that system structure is the, “The long-standing, largely implicit shared values, beliefs, and assumptions that influence behavior, attitudes, and meaning in an organization” (Piña et al, 2015, p. 672). System resources are the infrastructure of an organization. Piña et al. (2015) describes system resources as both the formal and informal components of an organization (p. 672). The formal and informal components are: workers such as physicians and nurses, technology used in procedures, the finances of an organization in both allocation of funds and reimbursement, the flow of information, the patients themselves, and the professional education (Piña et al, 2015, p. 672).
Both system structure and system resources are key components in maintaining the status quo of the quality of care a patient receives. System processes is the part of the framework that is essential in not only maintaining the quality of care but to offer quality improvement in care.
System processes is defined as the methods used to provide quality health care service (Piña et al, 2015, p. 672). System processes allows the formulation of care teams to care for a patient, and this will increase the care coordination and collaboration in a patient’s care. Staff is essential in educating patients in the types of care they have or will receive. But the patient and their families can partake their beliefs and culture onto workers in a hospital to expand the quality of care they would inevitably receive (Piña et al, 2015, p. 672). Another framework element is systems outcomes. The coordination of the previously mentioned framework elements alone with system outcomes also allow the enabling of a cost-effective, patient-centered care (Piña et al, 2015, p. 672). The unison of system structure, system resources, system processes, and system outcomes leads to a quality improvement of care.
The final framework, system outlook, is important for the future of healthcare. System outlook is defined as “projecting the future” (Shi & Singh, 2017, p. 24). System outlook is essential in the sense that is in preparation for the changes in healthcare. System outlook takes into account research and development of new treatments and technologies, and how to implement them. System outlook is a review of how to improve healthcare. The five elements of the framework are all involved in improving healthcare. The complexity of the framework has led to a fragmentation of the healthcare system. According to Piña et al. (2015) increased fragmentation has led to the creation of new and often negative relationships between fragments (p. 670). And essentially the framework, as it is currently, forms the basis of the characteristics of U.S. healthcare.
The characteristics of the United States healthcare system are what forms up the basis for the healthcare system. Within the U.S. there are 10 main characteristics in which form the health care delivery system these include: No central governing agency and little integration and coordination, technology-driven delivery system focusing on acute care, high in cost, unequal in access, average in outcome, delivery of health care under imperfect market conditions, Government as subsidiary to the private sector, fusion of market justice and social justice, multiple players and balance of power, quest for integration and accountability, access to health care services selectively based on insurance coverage, and legal risks influence practice behaviors (Shi & Singh, 2017, p. 13).
The main characteristics of U.S. healthcare are not perfect. According to Shi & Singh (2017) the main purpose of a healthcare delivery system is to provide cost-effective health services (p. 13). The second purpose of a health care delivery system is to make sure healthcare provided “meets certain established standards of quality to an entire nation” (Shi & Singh, 2017, p. 13). This is not the case within the United States health care delivery system.
In order to make improvements, the belief is that changes should be made in technology-driven delivery system focusing on acute care and delivery of health care under imperfect market conditions. Medical technology refers to the practical application of scientific knowledge to improve people’s health and to create efficiencies in the delivery medical care (Shi & Singh, 2017, p. 110). In its many forms, medical technology is diagnosing, monitoring and treating virtually every disease or condition that affects us (Patrick, 2018, pp. 6). Medical technology can be familiar, everyday objects such as: sticking plasters, syringes, prescription spectacles, wheelchairs and hearing aids. At the high-tech end medical technology includes total body scanners, implantable devices such as heart valves and pacemakers, and replacement joints for knees and hips. Technology can also be the use of new and innovative supercomputers like Watson the IBM supercomputer (Patrick, 2018, pp. 7). The common thread through all applications of medical technology is the beneficial impact on health and quality of life.
Another way improvements can be made in the technology driven system is by the providers. Within the U.S. research and innovation in new technology creates a demand for new services. These latest innovations provide the best care; unfortunately this improved care comes at a cost. Clinical outcomes are not evenly distributed across the United States healthcare system (Vitaleri, 2016 , p 13). Vitaleri (2016) states in his journal that globally as economies grow and developing nations become more affluent, individuals will demand better care and fuel the advancement of medical interventions. In their journal Hackbarth & Berwick (2012) state that in 2011 healthcare in the United States accounted to almost 18% of the gorss domestic product (p. 1513). Estimates depict that in the U.S. costs will rise to $5.4 trillion by the year 2024 (Vitaleri, 2016, p. 12). In the United States increasing costs plague the industry and as the previous estimate shows is that it shall only continue. Vitaleri (2016) states the following as problems:
… plagued by fragmentation in business models and processes,… uneven distribution of profits,… concentration of margins among industry producers (pharmaceuticals, biotech and medical devices),… dispersion in… quality of clinical outcomes, and… preferred use of emergency care departments for diagnosis and treatment… are the most visible problems. Even after the ACA, significant gaps in access and care service levels exist. (p. 13-14)
Katuu (2018) states that the fragmentation leads to inequaties a bias towards curative rather than preventative services (p. 136).
The healthcare industry in the U.S. is imperfect and driven on competition. Within the U.S. healthcare system, healthcare is only partially governed by free markets (Shi & Singh, 2017, p. 14). The U.S. health care market is imperfect because it does not meet the classical criteria of a free market. For a health care market to be free, unrestricted competition must occur among providers on the basis of price and quality (Shi & Singh, 2017, p. 14). Currently alliances are being formed amongst healthcare providers; as a result competition is being further decreased (Shi & Singh, 2017, p. 14). Alliances and a decrease in competition are very detrimental to the choices a patient can make. Less competition leads to less avenues for a patient to seek opinions and knowledge for their medical care. Rogers & Walker (2016) state in their journal, “… healthcare can resolve uncertainty by providing a diagnosis, allowing patients to make sense of their experiences” (p. 82). The best consumer is a well-informed and educated consumer (Shi & Singh, 2017, p. 14). The removal of these cost disparities will improve access to healthcare.
Disparities in health and health care are pervasive and have continued to plague the health care system despite increasing recognition among patients and providers of their existence. Disparities, or inequities, are defined as undesirable differences in outcomes or care and are generally not driven by informed differences in expressed patient preference (Shi & Singh, 2017, p. 45). Meaningful and concerning inequities are prevalent in all spheres of health and disease. Inequities exist in both health outcomes and in health care and arise from myriad contributors (Erlen, 2009, p. 184). Erlen (2009) states reasons for disparity in her journal, “Health disparities occur when people are treated differently on… basis of a given set of defining characteristics… socioeconomically disadvantaged… racial/ethnic group… children… elderly… people of rural areas (p. 184). More factors leading to disparity are: homelessness, gender, health literacy, those suffering from chronic conditions, and being uninsured (Shi & Singh, 2017, p. 279-280). These factors are all barriers for these populations to gain meaningful quality of care. For care to increase healthcare should follow the bible verse, “Do not look on his appearance or… the height of his stature… For the Lord sees not as man sees: man looks on the outward appearance, but the Lord looks on the heart” (1 Samuel 16:7 English Standard Version).
Racial and ethnic minorities receive diminished healthcare compared to Caucasian American. Salmond & Echevarria (2017) state, “People of color face enduring and long-standing disparities in health status including access to health coverage that contributes to poorer health access and outcomes and unnecessary cost” (p. 15). The issue of health coverage also affects children, those in poverty, disabled, and elderly. These vulnerable populations in comparison to those that can afford their own health coverage cannot afford quality healthcare. Each categorized group of people has higher than not ratios of suffering from some ailment. There could be a chance of higher death rates, in which life expectancy is a key indicator of inequity in health outcomes (Ayanian, 2015, p. 1). Schulte (2009) states in her book that although life spans have increased across the entire population, there is still a disparity between men and women. Indigent populations can also have higher rates of heart disease, diabetes, high blood pressure, cancer, and higher risks of contracting and having HIV/AIDS (Ayanian, 2015, p. 1). Healthcare is not an entitlement, but a basic human necessity for life.
Over the course of time healthcare policy had been reformed and programs were added to cover the vulnerable and underserved populations in the United States. Erlen (2009) states, “Healthcare reform is necessary to address existing… disparities and thereby improve healthcare access, increase services, and ultimately health and quality of life” (p. 184). Examples of health programs, or policy reforms, in the United States that aid in expanding healthcare coverage would be: CHIP, Medicare, Medicaid, and the Affordable Care Act (Schimmel, 2016, p. 52). The health care in the United States is in stark contrast to healthcare in other countries. Most of the healthcare characteristics listed previously are different than what it is Canada. For example, in Canada the government utilizes what is known as the National Health Insurance system, which is a government run health insurance system covering the entire population (Akinlaja, 2016, p. 5). Akinlaja (2016) mentions, “… policies governing… healthcare… in Canada are often modified to ensure… they meet … definition of ‘universal’… the program in Canada covers … 97% of the… population, while… remaining 3%… are funded by other government programs in terms of healthcare” (p. 5). While in the United States there is no ‘universal’ health care program, there is only Medicare and Medicaid programs (Akinlaja, 2016, p. 6). In the United States Medicare covers the elderly in our population, and Medicaid covers those with disabilities and low-income (Akinlaja, 2016, p. 6). The cost between the healthcare in the United States and other countries has a huge disparity. It is more expensive in the United States than other countries due to privatization and the multiple players involved in healthcare (Akinlaja, 2016, p. 7). Private insurance is quite expensive in the United States whereas Canada has universal healthcare covering its population. Akinlaja (2016) mentions in her thesis, that although the United States has access to more advanced technology and research that the quality of care is not as good as it is in Canada; and healthcare is not accessible to the entire population in the United States as compared to the United States (p. 25).
There is a major issue in mismanagement and distribution of resources. The importance of patient-centered care and effective cross-cultural communication as a means of improving quality, achieving equity, and eliminating the significant disparities among racial and ethnic groups in health care that persist today (Ayanian, 2015, pp. 3). Caucasian Americans receive better care than racial and ethnic minorities. According to Salmond & Echevarria (2017) people of color face enduring and long-standing disparities in health status including access to health coverage that contributes to poorer health access and outcomes and unnecessary cost (p. 15). According to Salmond & Echevarria (2017) African Americans and other racial minorities have a cost burden higher than Caucasian American (p. 14). Latinos receive worse care than non-Latino Whites for about 60% of core measures (Salmond & Echevarria, 2017, p. 14). Reforms are needed to decrease this disparity. Chen et al. (2016) states the following about the Affordable Care Act: “uninsured rates have… after implementation of… ACA for all races and ethnicities… uninsured rates in 2014… reduced by 7% for African Americans and Latinos 5%…” (p. 3). The ACA is a benefit but disparities remain. The reductions in the probabilities of having any delayed or forgone care range from 1% for whites to 6% for Latinos (Chen et al, 2016, p. 3).
Weaver et al. (2010) in their article discusses the prevalence of forgoing care due to financial concern in a representative sample of US adults to determine if cancer history and race/ethnicity are associated with likelihood of forgoing medical care. Many US cancer survivor’s live years after diagnosis, emphasizing the importance of health care access for survivors. Weaver et al. (2010) states in their journal, “Despite their great need for medical services, cancer survivors may experience barriers to accessing care. Cancer treatment may result in financial hardship and inability to afford medical copayments, prescription medications, and medical services perceived as being non-essential” (p. 2). Multiple factors contribute to disparity in healthcare, including barriers in communication failure, a fragmentation due to healthcare framework, and clinician biases (Salmond & Echevarria, 2017, p. 15). It is unlikely any single intervention to improve treatment adherence or screening rates.
Healthcare always has room for improvement and is always changing. Improvements occur due to new technologies, healthcare policy reforms, and a more patient-centered care. In his journal Feussner et al (2016) states, “Sir Winston Churchill is quoted often to have said, ‘To improve is to change; to be perfect is to change often’” (p. 1). In the future, it will be as the bible says, “That the man of God may be competent, equipped for every good work” (2 Timothy 3:17 English Standard Version). Technology has benefitted man just as the bible verse says, “Behold, they are one people, and they have all one language, and this is only the beginning of what they will do. And nothing that they propose to do will now be impossible for them” (Genesis 11:6 English Standard Version). Per Shi & Singh (2017),
Technological innovations in the areas of advanced imaging, minimally invasive surgery, genetic mapping, regenerative medicine, etc., will help shape the delivery of medical care in ways never imagined. Many of these developments will likely shift the focus of medicine from the acute phase of illness to prevention and aftercare. (p. 358)
The usage of technology in healthcare is a great innovation, but challenges have arisen due to the use of technology. One major challenge in healthcare that has arisen because of new technologies is that of cost, another challenge is that of health disparity. Also, the lack of health professionals trained to use them. Dhawan et al. (2015) states the following:
Technology innovations and globalization have brought the world together as one global community where developing and developed economies have become more dependent and well connected than in previous times. As the overall life expectancy across the globe has increased, the global community is now facing new challenges of improving quality of life and healthcare at an affordable cost… the implementation of… healthcare technologies towards a tangible clinical impact poses formidable challenges in educating users… also what poses a challenge is infrastructure support and how burdensome it is for hospital facilities the usage of new technologies. (p. 1, 5, 10)
Some of the challenges that are brought on by the usage of new technologies will promote benefits and positive changes in the head care industry. Vitalari (2016) states in his journal,
Industry transformation will be marked by significant… structural changes as innovations in digital technologies, health sciences, health consumer engagement and medicinal practices play out… regulatory directives and care delivery objectives will drive increased industry transparency, information sharing, and collaboration… advances in genomics will deconceptualize disease typologies, diagnostic tools, and therapies, and… heightened emphasis on the quality of the health consumer experience will push policy makers and care providers to reform business models and industry economics. (p. 7)
A second way to ensure quality improvement in healthcare is through reforms. As mentioned previously, the challenge in using technology and healthcare in general is cost. Cost is a major factor throughout healthcare, and reforms in healthcare policy will help mitigate these costs. Hauswald & Skylar (2017) state, “The United States has more than tripled its spending in health care during the last 50 years, with 2013 expenditures representing 17.4% of the gross domestic product” (p. 249). With higher costs it is expected that the quality of healthcare should be better as well, but that is not the case. Hauswald & Skyler (2017) state, “Life expectancy is lower and measures such as infant mortality are higher in the United States than in most countries in the developed world” (p. 249). Reforms have occurred throughout history to successfully improve the quality of care and access to healthcare to middle class and economically disadvantaged Americans (Schimmel, 2016, p. 112). Congress is needed in reforming healthcare and to review the status of healthcare (Marjoua & Bozic, 2012, p. 267). Cost has a major effect when it comes to how much healthcare someone is willing to spend on, therefore results in them not receiving adequate healthcare. Atella & Conti (2014) provide statistical information comparing the cost of healthcare, “… costs raise by 35% for 60-year-old individuals, by 24% for 70-year-old individuals, by around 17% for those aged 75%” (p. 15). Felland & Reschovsky (2009) state, “In 2007, one in seven Americans under age 65 reported not filing a prescription in the previous year because they couldn’t afford the medication, up from one in 10 in 2003” (p. 1). The elderly are not the only underserved population in the United States, other populations including the uninsured and minority groups are deeply affected by cost. The goal of healthcare is not to serve only “pro-rich” or “pro-poor” (Marchidon & Allin, 2016, p.163). Iglehart (2014) mentions, “One of the least explored yet most important parts of the Affordable Care Act… are provisions that hold promise for addressing serious health care challenges facing people who… are impoverished and uninsured” (p. 358).
Reform is needed to help improve care for all populations in the United States. Both Medicare and Medicaid are government-funded programs that were created to help certain populations that are underserved (Rajaram & Bilimoria, 2015, p. 25). The Affordable Care Act (ACA), mentioned briefly earlier, is one of the more recent reforms to healthcare. The ACA is a way to solve the healthcare crisis in the United States. With an estimate of 50 million people uninsured, which is almost 15 percent of the U.S. population, the ACA is a great solution to bring quality care to all (Salmond & Echevarria, 2017, p. 16). Despite its intended goals it is not universal healthcare program, but it improves access to healthcare for many populations in the United States. The ACA is not perfect, but neither is traditional universal healthcare. In other countries universal healthcare is a government run health insurance. And the positives may be that, unlike here in the United States, there would be less stakeholders and possibly less fragmentation. The negatives are that individuals have long wait times to receive quick healthcare especially care that requires specialized technologies (Akinlaja, 2015, p. 9).
A third way to improve healthcare is through changing the way we care for patients, mainly changing care to a patient-centric model. Patient-centered care involves changing the dynamic of the physician-patient relationship. Also, patient-centered care involves involvement from a wide array of health practitioners. Mainly the health literacy of the patient is imperative for the patient themselves to be able to decide on their own treatments (Primeau, 2016, p. 2). The evidence-based knowledge that a trained physician provides the foundation for a diagnosis (Schulte, 2009, p.153); while nurses act as the patient’s advocate to treat them while the primary physician of care is there to treat them (Bartol, 2015, p. 15). Patient’s and their families have a voice and its imperative that healthcare practitioners involve the patient in the treatment. Human beings come from all sorts of cultures, geographies, demographics, and have their own family health history. Participation in their own care allows a physician and other healthcare practitioners to treat the patient with complete coordination and integrity (Nabatchi & Leighninger, 2015, p. 133).
Having a holistic approach to care successfully leads to improved quality of care and patient satisfaction. Having a balanced synergistic relationship with a patient makes care effective (Adinolfi, 2012, p. 239). Personalization is the key to improved healthcare (Patrick, 2015, p. 129). In his journal Pack (2016) writes about P4 medicine, which is an integration of systems medicine, technology, and consumer-driven healthcare (p. 1456). The 4 P’s in P4 medicine are: personalization, predictive, preventative, and participation (Pack, 2016, p. 1456). The concept of P4 medicine is supported by the using a hybrid of the technologies mentioned earlier of genetics and the likewise, a hybrid model of care that integrated evidence-based knowledge, and the personal views of the patient and their families (Kløjgaard & Hess, 2014, p. 135). Luck et al. (2014) further validates the concept of personalized care by stating, “To have multiple voices allows more sources for data input to choose the proper treatment. Allowing for perspective is a way to educate oneself on openness to reform” (p. 57). Patients and their families must be kept informed for trust to be created and nurtured. Healthcare reform and changes in policies are ideas worth looking into, but the infrastructure of healthcare such as administrations must be able to change with it (Pawson et al, 2014, p. 129). Trust is key for any relationship not only for those health practitioners that work with one another, but for the patient and the public to trust the medical care they receive.
Quality improvement is a major goal of the healthcare system. The concept of quality in health care is multidimensional and complex. It will take much unity and innovation to keep improving quality of healthcare. For those who seek to change they first must investigate the past to see what was broken. Different ideas, policies, usage of specialized technology, and models of care will lead to successful improvement of care. Medical care is always changing, but at its core it follows the Latin phrase bona diagnosis, bona curatio (good diagnosis, good cure).
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