Improving the Quality of Health Services: is the Regulatory Framework up to the Task?

Abstract

Over the last five years in particular, there has been a lot of discussion, debate and action in New Zealand aimed at addressing the alarming rate of iatrogenic injury, and the quality of health services in general. The rate of preventable adverse events that follow the provision of health services in New Zealand, whilst comparable to other countries with similar systems, is alarming. Whilst clinicians and clinical initiatives continue to strive for improvements in the safety of health services, there is substantial international support for the introduction of a 'system approach" to quality improvement which it is argued will assist in improving the quality of health services by changing the environment in which health professionals practise. Such an approach has been endorsed as policy in New Zealand by the Minister of Health. This thesis reviews the literature on the system approach and the theoretical bases underpinning the approach. The appropriateness of the system approach is considered in light of the legitimate need for taking punitive action against individuals in response to certain deviations from acceptable standards of practice. Part one of this thesis proposes a theory of quality improvement which sets out to achieve an appropriate balance between a system approach with the legitimate need for accountability and the taking of punitive action against individuals where the deviation from acceptable standards of practice is sufficiently serious to justify such a response. At the heart of achieving such a balance is the identification of a new threshold which, if crossed, will justify punitive action being taken against individuals. Because of the likely quality improvement benefits, this threshold requires significant departures from acceptable standards of practice. The second part of the thesis analyses the New Zealand regulatory environment and considers whether there is currently a system approach to quality improvement applied in practice, what thresholds are applied before punitive action is taken, and whether an appropriate balance is being struck between the system approach and the legitimate need for accountability such that improvements in quality can be achieved. This part includes a consideration of the perceptions of the regulatory environment held by those who work in the sector. To assist in this analysis, interviews were undertaken with, and a survey was distributed and completed by, a number of key stakeholders. The conclusions that are reached are that there is not a system approach followed in practice, that the current thresholds for taking punitive action against those who deviate from acceptable standards are both inconsistent and too low, and that there is not an appropriate balance between the system approach and the need for accountability such that the improvements in quality that it is said will likely follow the practical implementation of the system approach can be reaped. Significant legislative changes are proposed, including the introduction of a new statute, aimed at promoting quality initiatives that will assist in improving the quality of health services for the benefit of all health consumers. The law is stated as of 1 October 2004.