There are a number of reasons why providers of sexual health services might wish to measure quality. Advances in technology, economic uncertainty and increased media coverage of medical errors have created a focus on improving quality in healthcare by those commissioning services, and central guidance in many healthcare systems encourages providers to make services more patient centred. The need to improve quality is also driven by funding mechanisms which often reflect the number of patients attracted to a service and increasingly include a penalty for failing to meet minimum quality standards.
Quality encompasses patient safety, patient experience and the effectiveness of care. It is multidimensional and its interpretation may vary between commissioners, providers and patients. Despite this apparent heterogeneity, four key components of quality can be defined: accessibility, acceptability, effectiveness and efficiency.
Accessibility defines how easy it is for patients to get to, and be seen at, a sexual health service. The majority of sexual health patients self-refer, and therefore ease of access is an essential factor when choosing whether to attend a clinic or making a choice between different clinics. Measuring the accessibility of a service can be achieved by formally reviewing clinic location, transport links and parking facilities, although these may not be easily amenable to change. Physical factors, including disabled access, should be easier to change, with the aim of complying with local legislation. Providers have the potentially greatest influence over organisational issues, for example, the percentage of patients seen outside working hours.
Acceptability relates to whether the services provided are perceived to be satisfactory by the patient. Acceptability is also an outcome or consequence of care that may influence subsequent consulting behaviour and health-related decision making. In either case, evaluation of the opinions of both users and providers is needed.
Effectiveness is whether a service delivers care correctly when assessing the patient’s problem, undertaking appropriate investigations and giving the correct treatment. This encompasses clinic systems to deliver care, individual patient management, and ensuring patient safety.
The limited availability of healthcare resources (including funding, technology and labour) requires them to be used in the most efficient way to maximise outcome. A number of techniques have been developed to measure efficiency in healthcare, for example, cost-effectiveness analyses (the change in cost against change in outcome for a specific disease) and quality-adjusted life years (used in cost utility analyses to calculate the ratio of cost to number of years of life gained for a particular health intervention). New technology and changes in working practices offer the greatest opportunities to improve efficiency, but require an assessment of associated costs and benefits, which may be both financial and non-financial, for example, improved patient satisfaction, greater diagnostic sensitivity.
A shift in focus from volume to quality of care is increasingly driving change in sexual health services. However, if measuring quality is to translate into improvement in patient care, a number of key practical questions still remain to be answered, including:
Which bundle of measurements best discriminates between good and poor quality?
How can quality data be most effectively used to effect change and improve outcomes?