International Journal for Quality in Health Care 16:1-2 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Editorial |
New editor for a quality journal
Starting with the third issue of 2004, I will have the pleasure and the honour of taking over the editorial responsibility for the International Journal for Quality in Health Care. In fact, those of you who have submitted papers recently to the Journal may have noticed that manuscript assessments have been handled by the new editorial office as of December 2003, when the Journal’s online submission system became operational. Let me begin by thanking the International Society for Quality in Health Care (ISQua) for entrusting me with its scientific journal, and Dr Heather Palmer, who has edited this journal for the past ten years, for handing over a superb vessel for the scientific ideas of researchers worldwide who strive to improve health care. The handover of the editorial responsibilities was made particularly pleasurable by the joint efforts of Dr Palmer, Ms Morag Teek, the current managing editor, Mrs Lee Tregloan, Chief Executive Officer of ISQua, Dr David Ballard, ISQua board member in charge of publications, MrsMandy Hill, editor at Oxford University Press, and all members of the Journal’s Editorial Committee.My Top 5 list
I am currently head of the Quality of Care Unit at Geneva University Hospitals, and professor of health services evaluation at the Faculty of Medicine, University of Geneva (Switzerland). Rather than going into unnecessary detail of my past or current work, I will submit here my Top Five achievements, related to the role of editor of the Journal.
- I know a lot about poor quality in clinical care, in good measure through acts of commission. As an internal medicine resident (Geneva, 1984–1988), I have missed important clues in patients’ histories, prescribed multiple drugs without checking for interactions, failed to wash my hands when necessary, talked about patients in hospital elevators, dictated discharge letters so late that they were useless, accepted the attending physician’s opinion without asking for scientific evidence, and assumed that I—not the patient—knew what needed to be done.
- More recently, I have been involved in supporting, developing, coordinating, and evaluating quality improvement initiatives at a large university hospital system (1998–current). This has been an exciting activity. But beyond the merits of each quality improvement project, this activity has taught me that the whole is more than the sum of its parts, and that steering a large organization towards better performance is, to put it mildly, a challenge. To call a modern hospital a ‘complex system’ is a gentle euphemism. How about ‘semi-chaotic aggregate of professional activity and patient needs’, or ‘a stew of compassion and technology connected by divergent goals’?
- From my methodological training (a Master of Public Health, a Master of Health Science in Biostatistics, and a PhD in Epidemiology, from the Johns Hopkins University), I have acquired a good idea of how research should be done. Later, of course, I got a taste of the real world of health services research: eligible participants do not participate, programs change in the middle of the evaluation, health interventions have unanticipated side-effects, control groups get contaminated, and policy-makers make decisions without awaiting your carefully balanced and prudent report.
- To get closer to scientific editing: I know about refereeing manuscripts, both from reviewing manuscripts for various journals—all of these reviews striving for rigor and impartiality—and from responding to critiques of my own papers: some of these lacking in either or both.
- Topping this list of achievements, I have no experience whatsoever editing a scientific journal. This I suppose is all right, since no editor can completely mess up valuable work sent by researchers in the field.
Vision for the Journal
Although I am by nature rather sceptical, I am sure of one thing: that doing research and publishing the results is essential for advancing any field of human activity. This is even more true for a field that is still at a fairly chaotic and unstructured stage. As I see it, quality in health care is only coming of age as a science. Not so long ago, the discourse on quality was dominated by charismatic gurus, strong beliefs, and schools of thought (I do not wish to be disparaging—such an early phase is necessary in any endeavour. People cannot listen until they have heard the message.) But increasingly, the discourse on quality reflects critical analysis, evidence gathering, innovation, discovery. Obviously, scientific journals play a key role in this transition: they submit new ideas to critical analysis, broadcast advances, and keep a record of who did and said what. I am both excited and humbled to be part of this adventure.
To fulfil its potential, the International Journal for Quality in Health Care should remain a global, interdisciplinary forum for scientific advances in quality of health care. Let me parse this sentence:
The journal should be ‘global’. It should be relevant to the quality of health care everywhere: in developing and in developed countries, in large hospitals and in single doctor practices, in high tech care and in preventive services, in rural areas and inbig cities. The readership of the Journal should include hospital quality managers, but also health care professionals such as nurses and doctors, health policy makers, health services researchers, elected politicians who administer health care, and even informed users of health services.
The scientific foundation of the Journal should be ‘interdisciplinary’, as a reflection of the complexity of the issues involving quality in health care. To improve quality, we need management science, clinical sciences such as medicine and nursing, clinical epidemiology, sociology and psychology of health, anthropology, human factors analysis and ergonomics, health economics, health care ethics, and policy analysis. The science of quality in health care is a mongrel science, and should be proud of it.
The Journal should not only be a passive depository of research on quality, but a ‘forum’ that spreads ideas, fosters debate (and sometimes nothing is better than a really nasty debate), stimulates high quality research, and draws young researchers to this domain of inquiry.
By ‘scientific advances’ I mean that the primary purpose of the Journal is to report generally valid knowledge, not simply to tell stories or to assert experts’ opinions. Because it involves tweaking complex non-linear systems populated with unpredictable individuals, research into the quality of health care is orders of magnitude more difficult than controlled laboratory research. I cringe when I hear people say that investigations into quality are too complicated to allow for rigorous research designs. This is a reason for demanding more rigour—not less—from the quality research community.
The Journal should be concerned with ‘quality’ in all its diversity. Quality can be subjected to several models of analysis. There are the core dimensions of quality, such as effectiveness, appropriateness, safety, efficiency, equity, accessibility, and patient-centeredness: other dimensions could be proposed. There is Donabedian’s trilogy of structure, process, and outcome of health care, Deming’s cycle of ‘plan–do–check–act’, and the more recent reformulations and reinterpretations of their ideas, such as the model of the European Foundation for Quality Management and various accreditation and certification approaches. All these models have their merits and should feel at home in the pages of the Journal.
Finally, it is ‘health care’ the Journal is interested in, not mass production of widgets. Some approaches to quality look impressive until they are confronted with the variability and the uncertainty that permeate disease and health care processes, and the complexity and paradoxes of human wants and needs. These facts are not just annoying noise that spoils neatly planned projects, but lie at the heart of quality improvement.
To conclude, let me invite all of you to take part in research to improve health care, and to share the results of your work in the pages of the International Journal for Quality in Health Care. Write for us!
Quality of Care Unit, Geneva University Hospitals, CH-1211 Geneva 14, Switzerland
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