Comparison of Patient Evaluations of Health Care Quality in Relation to WHO Measures of Achievement in 12 European Countries

By Kerssens, Jan J.; Groenewegen, Peter P. et al. | Bulletin of the World Health Organization, February 2004 | Go to article overview

Comparison of Patient Evaluations of Health Care Quality in Relation to WHO Measures of Achievement in 12 European Countries


Kerssens, Jan J., Groenewegen, Peter P., Sixma, Herman J., Boerma, Wienke G. W., van der Eijk, Ingrid, Bulletin of the World Health Organization


Introduction

In 2000, WHO reported an international comparison of health system performance (1). On the basis of five measures of health system achievement, 191 Member States were ranked (2). Improvements of the health status of the population and the equality of health status distribution across the population are two important goals that address the core business of health care systems. The third goal is to ensure fairness in the financing of health care, with expenditure reflecting a patient's ability to pay rather than their risk of illness (3, 4). Health care systems should also be responsive to the legitimate expectations of populations for non-health enhancing aspects, so level and distribution of responsiveness are the fourth and fifth goals. Responsiveness includes respect for dignity, confidentiality, and autonomy of persons, as well as client orientation (prompt service, quality of facilities, access to social support, and choice of provider). The measurement of the concepts of level of responsiveness ,and distribution of responsiveness are independent of the measurement of the three other goals (5).

As responsiveness addresses expectation and client orientation, it clearly is in the domain of patient views on health care. Donabedian defines quality as the degree to which health services meet the needs, expectations, and standards of care of the patients, their families, and other beneficiaries of care (6). Expectations are studied very often in health quality research (7-9). For example, according to a model proposed by Babakus & Mangold (10), patients' judgements about quality are equal to their perception of quality minus their expectations (11, 12), but the measurement of expectation is characterized by diversity in approach in terms of definition, content, and measurement (13). In practice, expectations can refer to ideal health care, anticipated health care, or desired health care, and sometimes people do not even have explicit expectations (14). Zastowny et al. and Sixma et al. took the desired health care approach by concentrating on normative expectations, importance scores attached to these normative expectations (importance dimension), and actual experiences (performance dimension) (15, 16). In this model, expectations are reflected in statements such as "Health care providers should not keep me waiting for more than 15 minutes". Performance relates to cognitive awareness of the actual experience of the use of health care services: for example, "At my last appointment, they kept me waiting for more than 15 minutes". Although performance refers to an actual situation, importance stores attached to the expectation component refer to the fact that some features of health services are more significant than others. Quality of care judgments (Q) of individual patients (i) can be calculated by multiplying performance scores (P) by importance scores (I) of different health care aspects (j). As a formula, this equates to [Q.sub.ij] = [P.sub.ij] x [I.sub.ij]. Quality of care stores reflect the patients' view of health care and how patients want to be treated by health care professionals on quality aspects that are particularly relevant to them, taking into account the multidimensionality of the concept. A great deal of overlap exists between WHO's definition of responsiveness of health care systems--meeting the needs, or legitimate expectations, of the population for non-health enhancing dimensions of their interactions with the health system--and the way quality of care from the patients' perspective is defined by Sixma et al. (16). The distinction between quality of care from the patient's perspective and from the perspective of other stakeholders--such as health care providers (for example, care according to professional standards or protocols) or managers (for example, care based on efficiency)--needs to be kept in mind.

In order to select relevant quality of care aspects, Sixma et al. …

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