PRACA ORYGINALNA

ORIGINAL ARTICLE

Quantitative assessments of the quality of medical care for patients in conditions of private-state partnership

ILOŚCIOWA OCENA JAKOŚCI OPIEKI MEDYCZNEJ PACJENTÓW LECZONYCH W PLACÓWKACH FUNKCJONUJĄCYCH W RAMACH PARTNERSTWA PUBLICZNO-PRYWATNEGO

Petro P. Hanynets, Natalia A. Sinіenko, Ozar P. Mintser

Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

Abstract

Introduction: The article discusses the problems of joint activities of public and private sectors to ensure the proper quality of medical services and jointly overcome financial and production risks. It is emphasized that if the financial and administrative issues of such interaction have been studied to a certain extent, then a quantitative assessment of the quality of medical care provided in a public-private partnership has so far raised questions

The aim: Identify ways to use industrial quality criteria for providing medical care to patients in public-private partnership conditions.

Materials and methods: The results of rehabilitation of 300 patients with gastrointestinal pathology who underwent rehabilitation in the resort “Kvitka Poloniny” of the TOV “Suzirya” were studied. 160 patients underwent rehabilitation in the private part of the resort, 140 – in the state.

Results and conclusions: The theoretical approaches to the use of scientific and technological tools for the implementation of public-private partnership in medical institutions, in particular in a rehabilitation center, are discussed. They are based on instrumental approaches to assessing the quality of medical care. The use of Pareto assessment techniques and the Taguchi loss function allows us to quantitatively characterize the improvement in the quality of care provided with the help of public-private partnership.

Key words: quality of medical care, quantitative assessments of medical care, industrial assessments of the quality of medical care, risk of adverse outcome, public-private partnership, Pareto efficiency theory, Taguchi loss function

Wiad Lek 2019, 72, 2, 246-249

Introduction

Public-private partnership (PPP) – an effective formula for increasing the efficacy of the national economy through the formation of cooperation between private partners and the state has become widespread recently. Despite significant progress in solution the issue of creating a legislative field of PPP, Ukraine is only at the beginning of a complex and lengthy process of institutional transformation of relations between the state and business. Difficulties in this process are associated with the necessity to prepare the “ground” for PPP, namely the creation of an institutional and organizational alliance of state power and business. Such an alliance should provide the definition, development and implementation of large-scale socially significant projects that can cover a wide range of activities in various sectors of the economy and operate within the framework of both the state and individual territories. The active development of various PPP forms, which takes place in almost all regions of the world, and their widespread use in the health care system of countries with different economies, makes it possible to consider this form of relationship as a characteristic feature of the modern mixed economy. It should be borne in mind that PPP in the health care sector, in contrast to traditional administrative relations, creates special models of property, financing and management methods relations [1–4].

It is worth to be emphasized that although today a legal framework that provides opportunities for developing the state concept of PPP in health care has been created in Ukraine, the criteria for the effectiveness of the quality of medical care have not been approved yet. At the same time, such criteria are crucial for the integral evaluation of the PPP’s utility.

The aim

Identify ways to use industrial quality criteria for providing medical care to patients in PPP conditions.

Materials and methods

The results of rehabilitation of 300 patients with gastrointestinal pathology who underwent rehabilitation in the resort “Kvitka Poloniny” of the TOV “Suzirya” were studied. 160 patients underwent rehabilitation in the private part of the resort, 140 – in the state. In fact, the studies were conducted in the same conditions by the same medical workers according to state standards. The use of mineral waters (“Luzhanskaya-4”, “Luzhanskaya-7”, “Polyana Kvasova”) and medical supplies was equal. However, the living conditions in the private part were better, patients could use advanced diagnostic and therapeutic options.

A special technique to assess and compare the effectiveness of rehabilitation was proposed.

Results and discussion

A set of questions related to the redistribution of property rights is fundamental in the process of development of PPP, since the institutional partnership is re-generating relations in the health sector, which traditionally belonged to state authority. In practice, this involves the development of mechanisms for the transfer to private partners of a certain part of the functions of the material and technical services of health care institutions at various levels (both public and municipal property), in particular, diagnostic studies, nutritional management of patients, disinfection, transport, household services, communications and the other. In the simplest cases (catering, laboratory tests) it really works. In more complex situations, the assessment of the usefulness of the association may be debatable. A typical example is the creation of parallel structures for the diagnosis and treatment of patients, where the logic of utility does not give a definite answer.

It is believed that the benchmarking procedure should be recognized as effective. It is proposed to compare the quality of medical care in its own health care facility with the quality on the market, primarily the one offered by competitors. Based on this information, it is recommended to make decisions concerning various aspects of the resort’s activities, including the feasibility of using various techniques and the possibility of rehabilitation technologies improving. But in reality it is not. An exceptional multi-factoriality due to the fundamental inconsistency of the rehabilitation conditions in various resort facilities, the incompatibility of the patients’ condition makes the task of the benchmarking infeasible.

Under the quality of medical care we will understand a set of characteristics confirming the compliance of the provided medical care with the patient’s (population’s) needs, expectations, the current level of medical science and technology, and under the continuity of medical care – the degree of coordination throughout the entire period of medical care for the patient (medical intervention) between practitioners, organizations. Finally, the coordination of medical care is understood as medical care in which the likelihood of an adverse outcome (or undesirable complications) at least does not increase.

In assessing the quality of medical care, the number of medical errors was taken into account. At the same time, the medical error was considered as the wrong action or inaction of the doctor, which made it difficult or could make it difficult to perform medical technologies, contributed to or could help to increase or stabilize the risk of the patient’s disease progression, the appearance of a new pathological process, and non-optimal use of medical resources. The significance of the medical error was also assessed by the magnitude of the likelihood of an adverse outcome and the degree of patient dissatisfaction.

An essential significance in assessing the results of medical care should also be attributed to the key characteristics that determine patient satisfaction (comfort, care, confidence, convenience, communication and cost). The integral characteristic of the patient’s subjective sensations made it possible to evaluate additional specific indicators of the rehabilitation process [5].

Thus, in assessing the quality of medical care, all recommendations of the World Health Organization were implemented. Namely, the following components of the medical care quality : 1) professional functions (or the realization of the therapeutic and diagnostic process), qualification of a doctor; 2) the risk to the patient due to medical intervention; 3) optimal use of resources; 4) patient satisfaction with provided medical care [6].

However, many different situations that we face every day, when it is quite difficult to determine the quality of medical care may be highlighted. In some cases, only one side is informed about the scope and compliance of the performed diagnostic and therapeutic actions – medical workers. In other words, the patient does not know what exactly he received, and the quality of medical care becomes clear much later. Potential patients, and sometimes potential expert groups, often hide the true goals of their behavior and use almost all methods for obtaining one-sided benefits. Patients with outpatient medical care often do not give all the information to the doctor that is important for determining the correct diagnosis. This situation, called information asymmetry, is of great importance in assessing the usefulness, optimality of medical care, and evaluating preferences when choosing a treatment strategy.

Accordingly, although the requirements for completeness, validity and accuracy of medical information have been postulated for more than the last two centuries, in fact they are not fully met.

Accordingly, in a conceptual strategy for assessing the quality of medical care, it is important to evaluate not only the optimality (utility), but also the loss function. We have selected the Pareto efficiency indicators (W. F. Pareto) and the loss function of Taguchi (G. Taguchi) for the integral industrial quality assessment of medical care.

However, the obtained estimate is too general. Detailing the approach associated with the use of industrial quality indicators of medical care.

A criterion approach was used associated with the logic of Pareto optimality determining [7–9]. The system state was considered as optimal when the value of each particular criterion describing the patient’s condition could not be improved with the deterioration of the values of other indicators. The set of Pareto optimal system states was called the set of optimal alternatives. The situation when Pareto efficiency is achieved is a situation when all approaches to achieving a more favorable result have been exhausted.

In this way, a narrowing of the acceptable solutions set to a set of effective solutions was ensured. It can be partially provided based on a preference analysis. We will consider a solution of course effective if there is no more preferred therapeutic approach.

If it is necessary to determine the effectiveness of rehabilitation for a group of patients, another Pareto’s rule can be used, considering that the state A is preferable to state G if at least for one individual state A brings a greater level of utility than state G without reducing the level of utility of any of the other individuals.

A multi-criteria assessment of rehabilitation for a particular patient can also be performed on the basis of the well-known Pareto selection rule: rehabilitation is considered preferable when there is no other option better than that given by at least one indicator and no worse than all others.

Accordingly, the choice of the best alternative was previously carried out in terms of achieving the goals set, resource costs, and meeting the specific conditions for the implementation of alternatives.

When deciding on the usefulness (feasibility) of one of the methods of restoring the patient’s ability to work, for example, after a stroke or other fairly complex clinical cases, it was often difficult to work out unambiguous recommendations on the preference of one alternative to all others based on the proposed quantitative calculations. Therefore, groups of preferred (effective) alternatives, also derived from Pareto optimization approaches, were identified.

The quality assessment of the diagnostic and therapeutic processes was obtained using the Taguchi toolkit, which, as is well known, boils down to the following postulates: a) it is impossible to reduce costs without degrading quality; b) quality improvement without increasing costs is also impossible; c) reducing the variability of the performance of the resort contributes to improving the quality and efficiency [10, 11].

The Taguchi method is based on a quadratic loss function. The value of the quality indicator is plotted on the horizontal axis, and the vertical axis shows the magnitude of the “loss” or “harm”. These losses are assumed to be zero when the quality characteristic reaches its nominal value.

The general algorithm is illustrated on Fig. 1.

Of course, consumers of services (patients, patients) want the quality level of medical care to be at point C, because they are trying to get the maximum recovery effect from efforts and money invested or to get the best result for the lowest price. However, from the point of view of service providers, point C is more consistent with optimal quality, since it reflects the most economical use of available resources and ensures a sufficiently high quality of medical care. In fact, the interval {C, A} may be a quantitative assessment of the medical institution work . In reality, with the quality work of a medical institution, we get point B, and the distance BA is a reflection of the medical team efforts to improve the quality of medical care.

They carried out a comparison of the resort performance before and after the creation of a complex on the basis of PPP, both in relation to clinical work, infrastructure, human resources, and specific results.

Clinical performance and average rehabilitation results were close, but in all cases requiring close attention and the use of expensive diagnostic and treatment technologies for PPP. It is important to note that the repeatability of the results was significantly higher. The number of medical errors decreased by 42% ± 3%. The integral evaluation by the Pareto and Taguchi methods turned out to be shifted towards PPP. The distance BA was 1.7 conventional units, which can be considered a quantitative proof of the effectiveness of the new format of the resort’s activities.

Conclusions

1. The theoretical approaches to the use of scientific and technological tools for the implementation of PPP in medical institutions, in particular in a rehabilitation center, are discussed. They are based on instrumental approaches to assessing the quality of medical care.

2. The use of Pareto assessment techniques and the Taguchi loss function allows us to quantitatively characterize the improvement in the quality of care provided with the help of PPP.

References

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Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Petro P. Hanynets

Shupyk National Medical Academy

of Postgraduate Education

Dorohozhytska St., 9, 04112 Kyiv, Ukraine

e-mail: t.duxowi41992@gmail.com

Received: 09.11.2018

Accepted: 29.01.2019

Fig. 1. The algorithm of the medical care quality evaluation.