Applying key performance indicators to evaluate health care service outcomes

While the World Health Organization (WHO) definition of health (“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”) is globally accepted, few health service evaluation systems include the voice of patients, despite the purported objectives of health service providers. The overall purpose of this thesis was to evaluate patients’ experiences of health services in Saudi Arabia (SA). Key performance indicators (KPIs) were used to explore the relationships between the structural characteristics of hospitals, the processes inside hospitals, and the outcomes of health care among patients attending accredited (ACCH) and non-accredited (NACCH) public hospitals. This thesis also identifies the reasons why patient well-being has not been included in the conceptualisation and routine measurement of hospital quality. Not having patient well-being outcome measures in health service evaluation in SA, as suggested by the WHO definition of health, is problematic and leads to lost opportunities to improve the quality of hospitals and the quality of care for patients. For the primary research question, this study included the feasibility for SA patients to provide feedback about their Quality of Life (QoL) impact in a structured survey. For the secondary research questions, the study assessed patients’ QoL, measured by WHOQOL-Bref instrument and Quality of Care (QoC), evaluated by a self-administered questionnaire, in ACCHs and NACCHs. In many health research outcomes, research studies have indicated a gap between patients’ experiences and their health outcomes. Using a formative evaluation approach, this thesis presents the results of a study that measured QoC, QoL, and demonstrated that it is both feasible and desirable to include these measures in outcome and hospital quality improvement studies. Patients’ perceptions of QoC and QoL were measured using standardised tools and were based on experiences during a single care episode that was tracked from admission to discharge. The conceptual framework for the public health system developed by Donabedian (1980) and House’s model (1978) for health evaluation were used in this thesis. The study particularly used the WHOQOL-Bref tool to measure health and well-being outcomes against access and effectiveness domains of QoC. The health measures applied in this study involve the structure, the process, and the outcomes. Structural measures were assessed by assessing key features of the delivery organisations. These include widely available access to tertiary health care and the policy environment in which health care is delivered. Process measures were evaluated by providing patients’ reports and experience about the treatment effectiveness and how hospitals maintain high standards, outcomes measures were monitored by applying QoL. The main study involved patients about to be discharged from four public ACCHs and four NACCHs in the Riyadh region of Saudi Arabia. Patients were randomly sampled using quotas based on hospital characteristics. Of 1200 patients invited to participate in the study, 1059 responses were received, a response rate of 88%. Cronbach’s Alpha analyses of the measurement tools employed in the study showed that the psychometric properties of the tools were satisfactory, with Alpha ranging from 0.600 to 0.858. As hypothesised, there were some statistically significant variations in the performance of both ACCHs and NACCHs in terms of the QoC and QoL domains. The median score of accessing the hospitals was 3.23 in NACCHs and 2.92 for ACCHs (p < .001). Statistical modelling using multiple linear regression based on ordinary least squares showed that access and effective treatment were identified as the predictors of health and well-being. For the patients attending ACCHs and NACCHs, the model explained 19.3% and 13.5%, respectively, of the variance in QoL, implying that the models have only moderate practical and theoretical significance. The key results in this study suggest that respondents were willing and had the desire to reveal their health status and were able to reflect upon the performance of the hospitals they attended. In this study, there was no clear evidence that good QoL was associated with whether the hospital had been accredited. Surprisingly, for some respondents, healthy behaviours were found not to be a significant predictor of QoL. It is argued that there is a need for further research studies about the effects of accreditation and the need to consider patient well-being when setting hospital standards. This thesis has argued that the dimensions of patient well-being that are specified in the WHO definition of health could feasibly and should be included in hospital quality improvement activities and studies. The major recommendation of the present study was to include the dimensions of health (physical, mental, social, and environmental) and well-being in the SA health system especially in hospital accreditation processes. Furthermore, quality of care improvement should measure access to health care and treatment effectiveness using standardised and psychometrically robust tools in conjunction with the existing KPIs in the Saudi health accreditation system. Future research could profitably include the investigation and identification of health access and effective outcome factors, and the development of KPIs that positively impact patients’ well-being on personal, organisational and academic levels.