Factors Determining the Quality of Surgical Services and Approaches to Their Correction in the Mandatory Medical Insurance System

The dissertation is devoted to a comprehensive investigation of the factors determining the quality of surgical services and the development of approaches to their correction within the system of mandatory medical insurance (MHI). The work substantiates the necessity of a differentiated approach to the expert assessment of surgical care quality, based on the evaluation of individual quality properties from the perspective of a systemic approach that takes into account the interaction of the system "producer — consumer — expert." The author developed a methodology for socio-hygienic research of the quality of surgical services, including three-sided expert evaluation by consumers, producers, and experts, as well as models for integral assessment and forecasting of quality at the individual and public levels.

The relevance of the research is determined by the persistence of cases of provision of surgical medical services of inadequate quality, as well as by the fact that a significant portion of the population receives this type of assistance within the health insurance system. The data revealed on cases of consumer appeals and on the frequency of adverse outcomes of surgical interventions essentially testify to the inadequate quality of medical services of this profile, which raises the question of further searching for ways to resolve the problems of quality of these services. In this regard, research has been conducted on the improvement of medical-organizational approaches to surgical care [184, 158, 29, 81, 175, 46, 72, 167, 242, 159, 16, 23, 103, 78, 223, 28, 290, 15, 215, and others], including on the improvement of the management of risk groups, forecasting the degree of risk of development of complications of surgical pathology, complications of surgical interventions, schemes, and standards of treatment and diagnosis for various forms of pathology.

In a number of studies, approaches have been proposed for the improvement of organizational forms and technologies of quality assessment of medical services, including those based on the use of extra- and intra-departmental expert evaluation of cases based on medical documentation, the conduct of reviews of patient complaints in the department for the protection of the rights of the insured in territorial funds of mandatory medical insurance on cases of provided medical services, the use of automated programs for quality assessment of medical care, and surveys of patients and medical workers [Boyarsky A.P., et al., 1993, Klimova L.P., 1996, Chavpetsov V.F., 1997, Groisman V.A., 2000, Kuchenko V.Z., et al., 2000, Dzukaev O.A., 2001, Vagano V.N., 2003, Grinenko A.Ya., Trishin E.M., 2003, Naigozina N.B., et al., 2004, Polkov I.V., et al., 2004, and others]. Research has been conducted on problems of the quality of medical care of various profiles (traumatological-orthopedic, neurosurgical, obstetric-gynecological, therapeutic, pediatric, and others) [Bersnev V.P., Polkov I.V., 1996, Gavrilova I.V., et al., 1997, Taranov A.M., et al., 2004, and others]. Isolated studies have been conducted concerning the initial state of patients, in terms of their awareness, medical activity, as well as the initial state of medical workers. At the same time, despite the numerousness of conducted scientific research on problems of the quality of medical care, there are no works concerning the substantiation of differentiated approaches to the expert assessment of the quality of surgical medical services, based on the definition of the quality of medical care (WHO) as a set of certain properties, which would provide information for the substantiation and development of an integrated model of quality assessment, as well as for the development of a differentiated forecast of the risk of its decline based on the factorial dependence of quality properties, which would ensure the optimization of medical-organizational measures for improving the management of the quality of services of this profile.

In the previously proposed methodologies for the expert assessment of the quality of the provision of medical services of a surgical profile, this approach has been practically undeveloped; the proposed methodologies do not contain criteria for evaluating the effectiveness of the management of each quality property of the provided surgical service. There are no data on the ranking of quality properties of surgical services by the intensity of identified defects, including data on the comparative assessment given by the consumer and the expert for a specifically rendered service, as well as data on a comparative analysis of the state of quality properties when rendering surgical services at different levels of the health care system of the territory, as well as in different regions of Russia. The significance of factors for preserving the quality of surgical services has not been studied from the perspective of a systemic approach to their identification, namely: taking into account the state of the system "producer — consumer — expert," including for the state of individual quality properties.

In this connection, it appears expedient to conduct a comprehensive socio-hygienic research of the quality of surgical services, which would provide comprehensive information on the social portraits of consumers and producers of these services, on the influence of identified characteristics on the state of individual quality properties of these services, as well as for obtaining information on defects of rendered services with subsequent differentiation by quality properties. Among previously conducted research, works aimed at solving these tasks applied to medical services of a surgical profile were practically absent.

The goal of the work was: on the basis of a comprehensive socio-hygienic research of the quality of surgical services, to scientifically substantiate and develop methodological and medical-organizational approaches to the optimization of the management of factors determining the quality of surgical services in the system of mandatory medical insurance.

To achieve the set goal, the following tasks were solved:

1. To develop a methodology for socio-hygienic research of the quality of surgical services, differentiated by quality properties.

2. To study the state of the resultant and structural components of the quality of surgical care at the territorial level in the system of mandatory medical insurance based on expert assessment and survey of consumer opinions.

3. To provide an assessment of the quality of surgical services rendered in the system of mandatory medical insurance using a methodology based on the differentiation of expert assessment by quality properties, with a comparison of consumer and expert evaluations in each case of service provision, and to identify coinciding and differing characteristics of the quality of these services in different subjects of the Russian Federation.

4. To determine the socio-hygienic, socio-psychological, and medical-organizational factors determining the quality of rendered surgical services in the system of mandatory medical insurance, including the role of the ratio of the level of individual satisfaction of the patient with the provided medical service and the level of public dissatisfaction with surgical care.

5. To scientifically substantiate and develop a complex of measures for improving methodological and medical-organizational approaches to the optimization of the management of factors determining the quality of rendered surgical services in the system of mandatory medical insurance.

The scientific novelty of the results of the research lies in the fact that

- for the first time, a methodology for socio-hygienic research of the quality of surgical services has been proposed, based on the differentiation of expert assessment by quality properties and the identification of factors determining it; a model of integral assessment of the quality of surgical services on a quantitative basis by quality properties and their parameters has been developed;

- for the first time, a comprehensive assessment of the structural component of the quality of surgical care has been given, including an evaluation of the quality of the base structure, as well as the quality of producers based on a methodology for assessing personal potential and the quality of consumers of surgical services in the system of health insurance, taking into account the level of quality of rendering these services and individual properties thereof;

- for the first time, a comprehensive assessment of the resultant component of the quality of surgical care at the territorial level has been given on the basis of a model of final results and a model of integral assessment of public dissatisfaction with this type of assistance;

- for the first time, an expert assessment of the process component of the quality of rendered medical services of a surgical profile in the system of mandatory medical insurance has been given, based on expert assessment differentiated by quality properties, using the degree of coincidence of consumer and expert evaluations; regional coinciding and differing characteristics of quality properties of surgical services in modern socio-economic conditions have been identified;

- for the first time, from the perspective of a systemic approach, the predictive significance of socio-hygienic, socio-psychological, and medical-organizational factors acting in the provision of surgical services in the system "consumer — service producer (medical worker — medical environment)" has been established, taking into account the influence on individual quality properties of this service, as well as the degree of coincidence of the level of individual and public dissatisfaction with this type of service;

- a complex of measures for improving methodological and medical-organizational approaches to the management of factors determining the quality of surgical services and the efficiency of its experts in the system of health insurance has been scientifically substantiated and developed, including a methodology for quality assessment of services differentiated by quality properties and their parameters, the use of basic average-territorial norms for the evaluation of quality properties, a model of integral assessment and forecasting of the quality of surgical services at the individual level by quality properties, a methodology for forecasting public dissatisfaction with the quality of surgical care, and the selection of managerial decisions for leveling and intensifying factors affecting the state of quality of surgical services.

The practical significance of the obtained results of the work lies in the fact that the data revealed during the research on coinciding and differing defects of rendered surgical services in different regions of the country, on the ranking of quality properties of these services by the frequency of violations identified based on consumer, producer, and expert evaluations, the proposed model of integral assessment and forecasting of the quality of surgical services at the individual level, the model of quantitative assessment of public dissatisfaction with the quality of surgical care and its forecasting methodology, may constitute a theoretical basis for the modification of the proposed technology of quality assessment of medical surgical services applied to the profiling of these services (pulmonological, cardiological, and others), as well as may be used in the formation of directions for the implementation of territorial programs "Quality Management in Health Care."

Implementation of the results in practice. 1. Data on the ranking of quality properties of surgical services based on three-sided evaluation (by consumers, producers, and experts) were used in an informational letter for full-time and part-time experts of the health insurance system "Quality of Provided Surgical Services in the Health Insurance System in Modern Socio-Economic Conditions," approved by the Federal Fund of Mandatory Medical Insurance (2004). 2. The methodology for integral assessment of the quality of surgical services and basic average-territorial norms for evaluating the state of quality properties of these services in modern conditions have been introduced into the practice of the Ivanovo, Arkhangelsk, Vologda, and Yaroslavl regions at the level of Territorial Funds of Mandatory Medical Insurance. 3. The educational publication "Optimization of Organizational Forms of Extra- and Intra-Departmental Quality Assessment of Medical Care in the System of Mandatory Medical Insurance at the Present Stage" is used in the educational process at the Department of Public Health and Health Care, Medical Informatics, and History of Medicine of the State Educational Institution of Higher Professional Education "Ivanovo State Medical Academy." 4. Proposals for the optimization of the management of factors determining the quality of the personnel potential, based on a methodology for forecasting the decline in the quality of surgical services, have been introduced into the practice of the Yaroslavl Regional Clinical Hospital.

Validation of the work. The work underwent validation at the interdepartmental conference of the State Educational Institution of Higher Professional Education "Ivanovo State Medical Academy" of the Ministry of Health of the Russian Federation. The results of the work were reported at conferences and meetings: "Results of the Work of the Yaroslavl Regional Clinical Hospital and Services" (Yaroslavl, 2004, 2005), "Quality Management in Health Care" (Moscow, 2004, 2005), "Actual Problems of Regional Health Care" (Materials of the All-Russian Scientific and Practical Conference, Ivanovo, 2003), international conference "Information Technologies and Society" (Turkey, 2004, Sicily, 2005).

The main provisions to be defended:

1. The quality of surgical services at the individual level may be assessed quantitatively using the model of integral assessment by quality properties proposed in the course of the research, at the public level — using the model of integral assessment of public satisfaction with the quality of surgical care, basic average-territorial criteria for the evaluation of quality properties of services of this profile, and has coinciding and differing characteristics of these properties in different regions of the country.

2. The basis for forecasting the risk of a decline in the quality of a surgical service may be the quality of the base structure, the quality of the structure of producers, and the quality of the structure of consumers of these services, the ratio of public dissatisfaction with the quality of surgical care and the level of individual dissatisfaction of consumers with the provided surgical services, the state of which may be assessed quantitatively using the corresponding models of integral assessment proposed.

3. The basis for the selection of managerial decisions when improving the management of factors determining the quality of surgical services may be a system of forecasting their action, representing a set of models for each quality property taking into account the identified factorial dependence of these properties.