What is Quality?If Quality is fitness for purpose - what purpose? - Purpose and excellence are not necessarily self evident.
In an occupational health service context, is the purpose:
If so, who is the beholder?
The worker's perception:
The manager's perception:
The Occupational Health professional's perception:
Standards of QualityIf the perceptions of quality are so different, is it possible to definea single 'gold standard'?
Is there likely to be a simple unitary 'league table' measure of quality?
Given the complexity of the issues - the answers to these questionsare almost certainly 'NO'.
Inadequate evidence based standards of practice in occupational healthare fundamental weaknesses. In many contexts there is a wide diversityof practice between occupational health services, and between differentcategories of occupational health practitioners ostensibly working to achievethe same end. Debate is needed about how Occupational Health is practised,what the aims and purposes are (and hence the measures appropriate to ensurequality) Often there is inadequate scientific evidence to justify a particularpractice. If that practice or policy is accepted uncritically as a qualityassurance standard or as an audit criterion, health outcomes in the longterm might suffer rather than benefit. Perhaps there is a case for a Cochranetype collaboration in occupational health, or a form of evidence basedoccupational medicine to help resolve this fundamental difficulty.
In the absence of rigid standards, one may have to compare observedstructures and practices against guidelines (see below).
Assuring and Measuring Quality in Occupational HealthOur response to the difficulties outlined above should avoid the two opposingpitfalls of 'nihilism', or of measuring anything that can be measured,- simply because it can.
Several approaches to assure quality and to conduct audit in occupationalhealth have been considered. If all of these were pursued to the extentto which they are individually advocated, a considerable amount of resourcewould need to be invested, and if this had a limited return, serious inefficiencycould arise. Moreover if an inappropriate choice of quality assurance standards,or of audit topics or methods is made, false (positive or negative) conclusionsmay be drawn about an occupational health service, and ineffective, oreven counter-productive, changes implemented.
Education and professional competence of occupational health professionals,as well as of managers, must not be overlooked in the quest for qualityassurance standards and audit criteria. In a controlled study investigatingchanges brought about by cycles of peer review audit, the effect of auditon the process of care was limited to one aspect of process, resultingin slight improvement, when compared to the much larger differences inthe process of care, associated with prior training and standards of competence.Thus issues of continuing professional/medical education, of so called'clinical governance' and of professional (re)validation are closely linkedto the pursuit of quality and its audit. You may wish to consult companion pages on self-audit which are in preparation.
Issues of quality and audit must address occupational health throughoutthe whole working organisation and not merely within its occupational healthservice. For example, an audit of the management of sickness absence byan occupational health service in isolation will have a limited value,if it does not also address the extent to which the organisation as a wholerecognises, accepts and implements appropriate referrals, as well as theensuing action to prevent ill-health and to rehabilitate.
It is essential to develop quality assurance standards and audit criteria,for those policies, structures, processes and outcomes which have a criticalbearing on occupational health care. All too often quality standards aredevised and audits undertaken in circumstances merely where it is easyto set arbitrary standards or to conduct simple audits. These may proveto be very poor surrogates for the true quality of care. For example, inone study, essentially no correlation was shown between response timesfollowing referral to occupational health service, and the peer reviewedquality of the response. It is relatively easy to establish quality assurancestandards, and to audit the use of, for example, occupational hygiene equipmentto measure gases, vapours or respirable dust, as well as lung functionequipment. However, it may be much more fundamental and important to questionwhether the correct hazard is being sampled, how and why the sampling strategyfor the workplace has been determined, and whether and to what extent appropriatelysensitive and specific questionnaires are being administered to the workersat significant risk.
Consider the issue of industrial audiometry, as part of a hearing conservationand monitoring programme. Clearly it is important to help assure qualityby establishing management systems for calling employees to undertake theiraudiometry, for regularly calibrating the audiometer, for recording and storing the audiograms, for recalling the employees after an interval,and so on.
But... good professional occupational health practice requires muchmore than that: the workplace needs to be assessed by suitable and sufficientnoise surveys, appropriate advice must be given regarding reduction ofnoise at source, personal protection etc. Moreover the appropriate employees who need Health Surveillance must be clearly identified. If impeccableaudiometry and systems management is applied to a poorly selected subsetof employees (while others at equal or greater risk are overlooked) or if inadequate steps are taken to reduce exposure at source and/or implement personal protection, then sadly good occupational health standards havenot been achieved.
ConclusionIt is essential to search for the fundamental "weak links" in the pursuitof audit and quality in occupational health both within the discipline as a whole, and within each and every workplace, where it must be practised.Scientific research, appropriate professional competence and debate betweenthe practitioners concerned will help achieve this. The pressure for qualityimprovement, and the advent of third party audits may help in some circumstances. However, if these pressures result in arbitrary quality standards or inauditing what can be audited rather than what should, they may lead to unwarranted self satisfaction hiding fundamental flaws in occupational health care.
ReferencesSeaton A, Agius R, McCloy E, D'Auria D. Practical Occupational Medicine Arnold publishers. London. ISBN 0 340 559365 Chapter 10, and Appendix 5.
MacDonald EB (editor), Agius RM, McCloy EC, McCulloch WJM,Miller DM, Paterson JC, Whitaker S. Quality and Audit in OccupationalHealth. London: Faculty of Occupational Medicine of the Royal Collegeof Physicians of London, 1995. (This report is available from the Facultyof Occupational Medicine of the Royal College of Physicians, 6 St Andrew'sPlace, Regent's Park, London NW1 4LB, Tel 0171-487-3414 ISBN 1-873240-000-X,Price £10)
Agius RM, Lee RJ, Symington IS, Riddle HFV, Seaton A. An Audit of occupational medicine consultation records. Occup Med 1994;44:151-7.
Whitaker S, Aw T-C. Audit of pre-employment assessments by occupationalhealth departments in the National Health Service. Occup Med 1995;45:75-80.
Agius RM, Seaton A, Lee RJ. Audit of sickness absence and fitness-for-workreferrals. Occup Med 1995;45:125-30.
Dyjack DT, Levine SP. Development of an ISO 9000 Compatible OccupationalHealth Standard: Defining the Issues. Am Ind Hyg Assoc J 1995;56:599-609.
An extended resource on audit in OccupationalHealth/Medicine is in preparation.
Acknowledgement and disclaimer:The work on which the above was based is the sole responsibility ofthe author. However a substantial part of the work was funded by a researchgrant from the Faculty of Occupational Medicine of the Royal College ofPhysicians of London, whose contribution is gratefully acknowledged.
Recent publications by the author on the subject:-