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Quality Assurance is necessity in Medicare as without it would be justifiably impossible to cure patients and their given illnesses. Lohr (1990) defines Quality Assurance as a methodically designed perspective that insures quality systems to maintain the specific quality requirements applicable for a product or service. It’s measured with customary standards achieved either through personal choice or optimal benchmarking and the given feedback ensures the level of quality achieved. Considering the feedback falls to a negative cycle, Quality Assurance helps recognize the researched quality ailments and then helps in fixing the weakness to create optimum service and product.
Standardization is very critical in providing best possible solutions. This becomes increasingly important in services sectors (Grimshaw, 1993). Hospitals around the world strive to meet global standards where they provide best possible service, the nature of work in hospital is extremely critical and it involves dealing with lives of individuals (Laffel & Blumenthal, 1989). Therefore utmost precautions need to be taken so that the best possible and accurate solution is provided to the patient.
According to Restuccia (1982) the major reason for hospital quality assurance malfunction is the negative assessment required to initiate a behavior in physician’s decision making ideology that would guarantee their ordering and utilizing essential and obligatory products and services. The prime motive for this is inadequate acknowledgment of the “intensive” expertise used to treat sensitive patients, a knowledge exemplified by the reliance of curative services and the patient’s reaction to these services.
1.2. Statement of the problem
Medical facilities are essential to human survival but they are not standardized in each country. Developed and flourishing countries have budgetary allocations to their public health care sector and their public hospitals and decorated with astounding state of the art technology and doctors that are ready to diagnose and fix any possible illness. This however isn’t true for all countries around the world; those in the stance of development have to suffice on the given private hospitals as they are the only glimmer of hope considering their public health institutions are failing.
“Quality Assurance in Government Hospitals of Saudi Arabia: Case of Hospital in Qassem” will help assessing the diversion of public health care facilities in the Kingdom of Saudi Arabia and compare it with flourishing public health institutions of the West.
1.3 Purpose of the study
The report will develop the parity between quality standards and actual practice in hospitals of KSA. The general norm of the Middle East and the African Peninsula considers public hospitals as ineffective and inefficient, the thesis paper will aim to generalize this convention and see if the general belief is correct regarding medical practices.
The research paper will help bridge the gap between medical facilities provided by KSA and hence comparing the quality standards of those medical associations with Western standards. It will help us check if the public hospital services in KSA are deprived of international health requirements and medical benefits and standardization.
1.4 Research Aims
The dissertation will aim to
Direct the health sector of the Kingdom of Saudi Arabia and hence develop a list of quality standards that will be used as comparison benchmarks with Western countries and their public hospitals known for their utmost advantageous medical practices.
This will help in comparing the provided medical facilities by KSA and then using them as variables for further reference and intense descriptive study.
The research will further aim to bring a factual potion between practice and theory and aims to bridge the gap between any disparities by identifying best international standard practices.
1.5. Research Questions
To accomplish the research aims and objectives we will take the help of defined research questions that will give base and foundation to the dissertation. The research questions are as followed:
Can quality standards successfully achieve improvement in performance or they are just there for the paper work?
What quality standards are maintained by Hospitals of (UK/USA/Germany)
How different are these standards to quality standards of hospitals in KSA
What relationship exist between written standards and actual practice of quality standards in KSA
What areas of improvement exist in raising current quality standards
What are barriers to higher quality assurance and standards
How can KSA hospitals learn from best international practice?
1.6 Research Hypothesis
H1: Hospitals in Qassem: Saudi Arabia follows standardized quality controls.
H2: Hospitals in Qassem: Saudi Arabia benchmarks their quality assurance with Western medical institutions.
H3: There is a discrepancy between public health institutions of Qassem: Saudi Arabia and those in Europe and America.
1.7 Limitations, Assumptions and Design Controls
The confinement of a study relates to those traits of plans or tactics that collide or manipulate the relevance or elucidation of the consequences of a study. They are the constrictions on simplification and the convenience of pronouncement that are consequential to the method in which the chosen layout of the study is acquired to institute interior and peripheral legitimacy (Lambert, 1992).
In this paper there were quite a lot of possible limitations. Many hospitals and their associated employees do not talk about the faults in the hierarchal structure and the technology advancement. Medical institutions are a healthy placebo for patients and the given interior staff didn’t want to shatter that illusion in any possible way. Collecting perfectly reliable data based on this was quite problematic for the validity of the research.
The dissertation aims to identify the diversion of medical utilities and facilities available for the public of Kingdom of Saudi Arabia. It will help recognize the key advantages and possible advancements in medical technology in KSA and also identify any possible problems that are experienced in providing optimal medical experience in the public hospitals of KSA.
This dissertation will be accomplished by utilizing various primary and secondary resources and the chapters after this will be categorized according to their important and their recognition in the research. The literature reviews in Chapter 2 will help identify the given associations and norms with medical facilities around the world and their development and standardization. The literature review will help us understand the basics of the research and why quality assurance is vital for the success of medical facilities.
Rowley (2004) examined the significance of a literature review by assessing its importance in supporting and guiding content in a research. According to Rowley (2004) a literature review is a synopsis of different literature regarding a subject field. Literature can be taken from different reliable sources to better understand the content of the research and other work done on the topic.
Different studies show that small precedence is consigned on patient’s expectations of service quality (Baldwin, 2002). Unlike products, service differs and not everyone can reap the exact same benefits as the other around. According to Carson (1998) the main reason behind a difference in judgment regarding the effectiveness of health care institutions is due to the difficulty of measuring the success rate as well as the performance and ways of those providing the service.
Quality in health services can be signified as the service that is needed by either an individual or a population (Morgan, 1990). Assessment of quality in healthcare is quite difficult as the results aren’t stable and constant but shifting. The success rate and the failure rate fluctuate constantly but morality rate is a variable that can be used to assess the performance of a health service (Renwick, 1992).
According to Tang (1999) there are three facets of quality management in hospitals, the first is recognizing performance and computing performance. The second step is deciding if the given standards match with the situation and finally the third idea talks about recovering esentation when standards are not met. According to Schaaf (1989) quality assurance and management is important as medical facilities are only for the benefit of patients and the sick hence the standards need to be written and designed that would greatly benefit those who they’re intended for. Identifying and measuring quality is difficult and according to Hammer (1993) quality assurance is quite important and Hammer’s (1993) research on 20 hospitals in Singapore showed the different quality management activities prevalent in those hospitals. The conclusion finally showed that there were three basic arenas of quality that had to be developed; a new service quality program for staff, quality orientation and feedback from patients regarding the service they received.
Design and conformance is an important aspect of quality assurance with regard to hospitals (Borys, 1996). According to Palmer and Dunford (2002), keeping the hierarchy of a medical organization small helps in maintaining effective quality standards as de-layering the hierarchy shortens the design and above every subordinate there is a watchful eye that helps increase motivation and withhold quality standards.
Quality in health care is not defined by standards only but by meeting customer demands. According to Garwin (1984) the mere aspects of quality in health care was around patient satisfaction, elements such as keeping appointments with patients and treating them professionally and checking their results constantly as well as their previous history showed quality and marked it. Apart from this doctors and physicians in public and private hospitals were told to adhere to carefulness and security, saying that these were two major quality assurance variables.
2.2. Different notions about quality assurance in health care
Bij (1998) suggests that quality in health care is a lot like that in an organization or another generic service. Quality in health care needs to be followed just like that in an organization or there could be lives lost, just like losses gone and customers lost. According to Vries research (1992) quality standards in health institutions need to be controlled, monitored and improved. Standards need to be set and controlled and then the given quality assurance methodologies need to be monitored to check if they’re followed and finally if there are any problems then they need to be improved or else the failure of quality assurance would lead to problems in the health institution in terms of medical performance and treating patients.
The basic motive behind quality improvement in health organization is to present patients with outstanding service by incessantly improving services (Balding, 2007). Organizations all around the world are now trying their best to improve patient safety and this is possible only with the help of quality assurance standards (Carool, 2007).
To take a step further, Eboch (1998) talks about different quality elements that need to be present and are important when it comes to quality assurance. In Eboch’s view quality assurance programs should apply to all medical institutions, from public and private hospitals to personal clinics, quality methods need to be measured and some basic variables should be assessed regarding quality, these can be the quality of treatment that is given to patients and the infection or death rates prevalent in the hospital. Apart from that quality assurance in hospital shouldn’t stick to medical facilities only but also should be looked upon in depth regarding patient and “family” satisfaction, meaning a good waiting area and good food available to not only the patient but to those who stay with them.
Jackson (2004) talks about the start of quality management and assurance in the United States and how it has developed in time considering technology and consumer requirements. The first medical standards that were set were by the American College of Surgeon’s. They decided to implement certain standards when it comes to quality assurance in medical treatment and tried to follow these guidelines; organizing the hospital and its staff, hiring staff that was experienced and well-learnt, medical records needed to be stored and insured so that in case a patient returns his/her history would be already available to fasten time and cut down costs. Once these bases for medical quality were stated soon others followed; in 1996 newer medical standards were built and these required medical trainers and doctors to coordinate work with welfare, provide good treatment to both public and private hospitals and also require intelligent and double checks on patient history and current situation before advising operations or serious measures. Most of the standards set by the American union in the 20th century provide basis for today’s standards in medical health.
Kilo, (1998) revolutionized the way of quality assurance in medical care in the American peninsula. He developed a continuous quality improvement and assurance plan that recommended all medical institutions to develop a separate quality assurance department and not involve medical physicians in them directly, apart from this Kilo talked about emphasizing the patient and doctor relationship and also investing in constant improvement in regard to quality. Doctors were also advised to avoid jargon language in hospital management and with patients and also training all hospital staff and management to understand the standards set up by the hospital administration and adhere to them.
Apart from Kilo, Dalley (1990) conducted a study with the Department of Health in York University and tries to asses the quality standards set up by the health authorities there as well as other places affiliated with York. It was seen that nearly all medical institutions, both public and private took quality management quite seriously and identified different quality assurance methods to improvise quality in their institutions. It was seen that most institutions had hired special managers who overlooked quality assurance and they were specifically hired due to their previous background in medicine. Apart from this these managers conducted quality reviews twice in a month and also tried to establish quality improvement methods after quality assurance was done.
2.3 Importance of quality assurance
In his study, Ronen (1995) described the importance of quality assurance and why it had to be implemented in health care. According to his observational research on hospitals in Israel it was seen that without quality assurance there was no general control or standard available to which actions had to be done. Doctors and nurses acted on their own accord, treating when they liked and using non-methodological ways. From 10 hospitals, 6 were given quality control manuals to follow and the rest 4 could do whatever they wanted to on their accord. The research led to the validity and proof of the statement that without quality assurance and control, medical health and health-care could not prosper as there wasn’t any rule or law to be followed which caused distress.
2.4. Assessment of quality
Hill (1991) assessed different ways of assessing quality control in health care institutions. According to him observation was the first best evaluation technique but it had its disadvantage as doctors and nurses had significant idea about their assessment and performed better than they would on usual days. Technological devices such as cameras can be used but this raises the ethical notion of consent.
Vuori (1988) examined the state of quality assurance in medical institutions during the 20th century. According to her research on hospitals around America and Europe it was seen that doctors in the 20th century thought of themselves as overconfident and hence did not need any controls or manuals to assist them on how work needed to be done. Before quality assurance standards were designed for health care facilities different tools were used to assess the conformity of health care services (Steven, 1996). An instrument known as the SERVQUAL determined the tangibility, reliability, responsiveness, assurance and empathy in customer discernment and this was later applicable in medicinal organizations as well (Scardina, 1994).
Understanding the versatility of a word with regard to its field and context is quite significant (Shaw, 1986). Healy (1988) examined different terminologies in quality assurance with reference to health care and considering quality assurance refers to activities and functions concerned with the attainment of quality, it needs to be understood with reference to health care.
Robinson (1995) assesses quality assurance and its significance in health care. In his research he implemented quality assurance programs in both public hospitals and private hospitals to assess the change in staff and medical performance. His results showed that the implementation of quality assurance manuals and quality control checks increased staff performance in both types of hospitals.
In her study, Rachel Fleishman (1996) designed a practical structure for the assessment of intervention programs to extend and advance the quality assurance methods in public hospitals. Her design tested three elements in quality assurance, process evaluation, impact evaluation and summative evaluation. Her research showed that although the quality assurance design was implemented, the new change wasn’t happily adopted by the hospital management. Conclusively the quality assurance design didn’t help increase the performance in hospitals and the design failed in regard to quality assurance.
Naveh (2005) examined the consequence of quality enhancement programs on hospital presentation. His research carried out on hospitals in Israel showed that quality implementation done on 8 out of 14 hospitals worked quite well, showing results of increased performance in both medical facilities provided as well as in the organizational hierarchy.
Quality assurance is a significant route but only if it’s paired with quality management (McKee, 2000). According to Hore (1994) quality assurance is nothing without quality management as according to her research she assessed six hospitals in the state of New Jersey and instigated both quality management and assurance in three and only quality assurance in the other three. Conclusively it was seen that hospitals without quality management did not care much about quality assurance and although followed the quality manuals and controls in the start, they soon fell to their own ways as their was no one to question or assess their motivation.
2.5. Quality differences in private and public hospitals
Throughout literature and people’s perceptions we find that nearly everyone believes private services to be more efficient, productive and promising than those provided in the public sector (Tian, 2000). Chaker (2003) compares the differences in quality assurance and regulations in private and public hospitals using Parasuraman’s SERVQUAL instrument for measuring quality, Anderson (1995) used this instrument to measure the services given by a health clinic that resided in the University of Houston Health Center. Anderson’s study showed that people were not fully satisfied in terms of quality as there was less empathy in hospital staff and they didn’t give much importance to patients in terms of constant checks and visits. . According to Chaker, this instrument is both reliable and valid when it comes to testing and has been used many times in measuring quality by hospital managers and directors. Chaker’s study was conducted in the Middle Eastern country UAE and 400 questionnaires were distributed in both public and private hospitals based on the SERQUAL instrument and the conclusion again showed that patients in public hospitals weren’t very pleased with the treatment they received and rated quality low in public hospitals saying that they could have received much better treatment in a private hospital.
According to Evans (1999) quality assurance is extremely important when it comes to measuring quality and standards but quality needs to be improved as well and that is done through constant quality improvement, an element that tries to measure the differences in quality and improvement in technology and perceptions and then implementing new changes in quality. Costin (1999) talks about the different items that help in identifying quality and then later improve it; these elements contain a quality committee that works in a special department donated only for the purpose of quality, a quality improvement plan and a budget that needs to be allocated to refer to quality improvements that need to be recognized.
Overtveit, (2001) talks about quality assurance and different quality methods in Japan. According to him quality assurance wasn’t implemented very seriously in Japanese healthcare but as times changed and as the world flourished the Japanese had to follow the Western tricks of quality assurance. The Japanese started using health care reforms to implement quality standards in health care and this pushed both public and private hospitals to start designing methods for quality assurance and management.
Ishikawa (1990) identified the initiation of quality assurance in Japan. According to him quality assurance methods started in the early 80’s but soon fell as those designing quality assurance standards were using methods those used in business management. Total quality management and quality circles were good ideas to implement but these did not reach a high point in Japanese quality assurance design as they realized that health care was a different task as compared to business activities and production.
As Ishikawa talks about quality assurance methods in Japan, Hazilah (2009) helped describe the quality management and assurance applicable in Malaysian public hospitals. Our study talks about quality assurance methods in the Kingdom of Saudi Arabia and it will assist our study to understand the quality assurance methods of another Muslim country with an economy such as that of Saudi Arabia. Hazilah (2009) conducted a research to understand the quality assurance methods in public hospitals on all levels; from city to state to national, more than twenty hospitals were assessed to provide a valid reasoning to his study. Usually publicly operating medical institutions try to benchmark the quality standards set by the private hospitals disposed in the private sector (Manaf, 2006).
Hazilah (2009) sent questionnaires to these hospitals and found out that were plenty of quality assurance and management techniques going on. Firstly the hospital staff met usually to discuss the quality arena in the public hospitals but this was done only in 16 hospitals out of total of 22, apart from this nearly all the hospitals that were tested showed the synchronization of employees and doctors together to benefit the patients and also showed most of the hospitals benchmarking techniques used by Western hospitals and some developed their own, showing that the current arena of quality assurance and management in Malaysia was going quite well.
Kume (1993) talks about standardization saying that respectable standards need to be set up before any objective is to be achieved but he also talks about the difficulty in designing these standards. Many say that setting standards sometimes limits innovations and new ideas (Okusa, 1985) but standardization is an important element in performance and in achieving goals, as standards divide strategies into good and applicable and bad and unrelated (Kondo, 2000).
2.7. Importance of standardization
Standardization is extremely important when it comes to health care, its one of the basic elements that keeps medical treatment correct and equal in all parts of the world (Shtub, 2010). According to Shtub’s (2010) research, standardization is a hospital is implemented in every action. Hiring doctors and nurses, designing and building emergency and operating rooms and even the entire architecture of the building needs to follow specific standards and entail standardization. In his research Shtub (2010) tried to develop a standardization model for hospital physicians and tried to develop different standards and preliminaries for hospital departments such as surgery, gynecology and pediatrics.
Apart from Shtub many other researchers have tried to design methods of standardization for medical facilities, Pelletier (2003) tried to design standardization models for employee staffing in hospitals but his study didn’t succeed as the complexity of health care is quite difficult and apart from private hospitals, the public hospitals in Pelletier’s research didn’t accommodate the design.
Many strategies have been created to help in standardization and Cruz (2006) remained no far behind. His design was a computer based system that would help in planning the hiring of physicians in hospitals according to given standards. His model tried to identify the total need for physicians in the hospital he was researching in by checking into all departments. Physicians who sent their proposals were checked regarding their CV’s and matching the elements with the given standards set by the software and they were then hired to represent the medical facility. Apart from Cruz, in 1991 the United States of American tried to design a standardization method for staffing physicians at the Veterans Administration Hospital (Libscomb, 1991). The committee designed two methods of standardizing the hiring of physicians. One was represented using a statistical model that worked much like Cruz (2006) model and represented the requirements for the physician and the given standards to match the two according to given parameters. The second model was developed when the first failed and combined the statistical software with an expert judgment model that not only calculated the parameters and their total but also showed the pro’s and con’s of hiring each physician and keeping him/her in the hospital.
Although standardization is applied all over the world with regard to quality control there are still many cultures that have promising health institutions whereas many are still trying to build medical institutions that follow a given objective (Paul, 2006). In his research, Ababaneh (2010) tried to assess the quality assurance in Jordan’s public hospitals. The results showed that although their were quality assurance standards required to be followed; many hospitals did not give them much importance and failed in accord of their quality.
According to Fagersorm (2001) standardization in hospitals regarding physicians and nurses is quite important. Both public and private hospitals in the entire European Peninsula have certain standardization models for its staff. Fagersorm (2001) breaks down these models into eleven categories. When the need for hiring a staff arises it is important to note that a staff needs to know 1) updating activities which include morning meetings and x-ray meetings with patients, 2) sick rounds that comprise of morning, evening and night rounds, 3) clarifications and collecting information which contains the task of computer, telephone and frontal clarifications as well as receiving reports, 4) interacting with patients and this not only included the patient but his family and also physical examination and taking blood, 5) conferring and consultation that comprises of consultation as well as staff briefing, 6) documentation, this includes the preparation of the letter of release and orderings x-rays and other medical examinations, 7) waiting, 8) administrative activities that includes planning and controlling, 9) research and study which requires the person to accompany students and conduct researches, 10) activities outside the department that consist of operation and consultation among other departments and finally 11) personal, which includes getting food and personal hygiene.
A major standardization method adopted for health care is the signified International recognized Standard for Quality Systems, the ISO 9000 (McCarthy, 1994). Using this standardization method all around the world makes it easier for institutions to measure the performance and quality of work done in health institutions in different areas (Rooney, 1989).
In his research, atham (2005) examined the performance of public hospitals in the Middle Eastern country; Oman. The collected results showed that from a total of 5 hospitals, 3 that were public did not show high performance in regard to medical facilities although they received a heavy amount of funds from the government. The 2 private hospitals on the other hand thrived as they had state of the art technology and doctors trained from all over the world earning heavy incomes.
2.8. Problems with quality assurance
Discrimination is sometimes noted as the synonym for inequality (Wendell, 2003), Discrimination in public hospitals is an old phenomenon (Kleiner, 2001). Kerim Ozcan (2011) identified the different elements of discrimination in public hospitals of Turkey. By conducting a research on health care employees it was seen that staff in public hospitals is a victim to discrimination. Nurses and female doctors are a victim of mistrust as people feel that they do not acquire the talent to be a doctor. Age was also found to be a negative point is younger doctors were found to be victims of discrimination as people preferred older doctors in public hospitals, stating them as they had more experience they were a more preferable choice.
According to Sturm (2001) there is a lot of “second generation” discrimination in public hospitals. Many don’t prefer female doctors or staff and reject their applications, causing gender discrimination and apart from this there is a basic discrimination of technology, quality assurance and operations. As public hospitals receive their funds to the board, most use them up for their own personal benefit leaving quite little for the hospital. Corruption is a an easy to find element in public hospitals (Acker, 2006) and considering this Sturm talks about the difficulty or negligence in implying quality assurance. Private hospitals need to make profits and a reputation to maintain considering they are expensive they will only attain patients if it has a name. A public hospital on the other hand will stay there, funded by the government hence efficiency and profitability aren’t the two main objectives of operating. Those who work in these hospitals try to forgo quality assurance considering they don’t really have any basics for standards and manuals to follow (Urwin, 2006).
Zernott, (1993) talks about another problem with quality assurance and that is the difference in a common currency. Economic theories don’t really come into the situation of health care but Zernott talks about the difficulty of operating and measuring quality assurance with standards considering that every country in a continent has a different currency. The budgets designed to issue and control quality assurance could be standardized but with the problem of fluctuating currencies it would be impossible to do so. Whatever budget the United Kingdom issues for quality assurance design it might be too c
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