Background
The Israeli National Program for Quality Indicators for General and Geriatric Hospitals, Psychiatric Hospitals, Mother & Baby Health Centers and Emergency Medical Services (hereinafter: the program) began operating in Israel in 2013 under the leadership of the Ministry of Health. The goal of the program is to measure the quality of clinical care provided in general, psychiatric, and geriatric hospitals, as well as in family health centers (‘Tipat Halav’ mother and child clinics) and pre-hospital EMT and ambulance services (‘Magen David Adom’ ambulances), in order to improve the quality of care for the benefit of all Israeli citizens. The program includes 70 currently active indicators, most of which have shown improvement since the start of measurement.
The Ministry of Health approached the Myers-JDC-Brookdale Institute to conduct a study to examine the attitudes of those involved in the measurement process towards the program.
Objectives
- To analyze the main organizational and operational changes that have occurred in the treatment organizations being measured in the program
- To learn about the attitudes of managers and care givers in the institutions being measured toward the program, its’ contribution and its’ impacts
- To examine how the care givers experience the program’s effort to promote and improve the quality of the medical care provided by them
- To examine the correlation between the attitudes of the managers and care givers towards the program and the extent to which their institution is meeting the program’s goals with respect to several selected indicators.
Methodology
The research included both qualitative and quantitative methods. Thirty, in-depth interviews were conducted with managers and relevant officials in the Ministry of Health, and in the institutions measured. A survey was conducted among care givers in the relevant institutions (1,449 staff members responded). The survey questionnaire included 54 questions and was distributed to staff members by the quality assurance managers in the institutions. In addition, data from the program’s reports published on the Ministry of Health’s website were analyzed.
Main Findings
93.0% of respondents believed it was important or very important to monitor the quality of care, and 64.0% of the respondents assumed that monitoring the indicators contributed to improving the quality of care. Interviewees also supported the need to monitor the indicators at the national level. However, there was criticism regarding the process of selecting the indicators, the number of indicators examined, and the focus on process indicators rather than outcomes, especially in the fields of psychiatry and geriatrics.
Some of the care givers felt that the program had positive effects. For example, 30.2% of physicians in hospitals (hereafter, physicians) and 37.3% of nurses in hospitals (hereafter, nurses) believed the program helps them become better caregivers. 19.6% of physicians and 43.6% of nurses reported that the indicators program significantly or very significantly improved their job satisfaction. Interviews revealed positive impacts such as technological advancement and the initiation of quality improvement programs in hospitals.
Respondents noted several challenges posed by the program, such as increased workload (reported by 61.0% of physicians and 71.0% of nurses), excessive competitiveness (reported by 28.0% of physicians and 37.8% of nurses), and excessive managerial pressure (reported by 74.8% of physicians and 71.5% of nurses). The interviews highlighted challenges such as directing attention to certain patients and a lack of indicators for other patients, as well as conducting unnecessary tests or treatments.
Another challenge pertained to the relationship with the Ministry of Health. Despite the ministry’s efforts to strengthen its relationship with the care givers, it appears that these efforts have not filtered down and, indeed, 89% of physicians and 69% of nurses felt that the ministry is only slightly, very slightly, or not at all attentive to the feedback from relevant parties in their hospitals regarding the program. Interviews also highlighted the unique role of the Ministry of Health inspectors and the challenges they face.
Despite the many challenges, 61.3% of respondents felt the program should continue, and only 25.3% felt that it should not continue.
Summary
The findings present a complex picture. On one hand, there is broad support for the program and the need for measurement. On the other hand, there are challenges that need to be addressed. It is very likely that the main gap in attitudes stems from the caregivers’ level of awareness of the foundations on which the program is built. Thus, proper mediation and exposure of the caregivers to the “behind the scenes” of the program may mitigate most of the hard feelings of the institutional quality assurance managers and the care givers, and perhaps even enlist them in favor of the program’s success.
Recommendations
- Engage the care givers to ensure the program’s success, among other things, by making them more involved in the program.
- Examine all measured indicators and their contribution.
- Establish a simple mechanism of communication between the physicians and nurses and the quality assurance managers in the various treatment settings, who will then convey the information to the Ministry of Health and ensure the care givers that the Ministry of Health is accessible and that their voice has been heard.
- Acknowledge the achievements of outstanding medical centers.