Sustainability of quality improvement in health care system or hospital in Saudi Arabia

Introduction

Among the domains that are prevalent within the healthcare organisation, sustainability is
considered to be a crucial one that contributes to the quality care services to the patients not
only at present but also in the prolonged future (Mortimer, 2018). When the prolonged impact
of healthcare is considered, it's varied impact upon the environment, and the community must
be comprehended as that in turn also affects the overall health of the population (Mortimer,
2018). With the aid of a sustainable approach, the value of healthcare outcomes can be
calculated in terms of its potential impact upon the environmental and social parameters
including the financial expenditures (Atkinson, 2010). In this regard, it must be mentioned
that the Royal College of Physicians (RCP) has broadened the sixth domain of the Institute of
Medicine to incorporate the aspect of sustainability as demonstrated in Figure 1(Royal
College of Physicians, 2011).

Fig: 1 Domains of healthcare quality (Royal College of Physicians, 2011)

It is very much desirable to us that we could sustain the modifications that had contributed
towards the quality augmentation of the healthcare sector (Royal College of Physicians,
2011). The adherence to the identical old methods of functioning that had already contributed
towards substandard results and also waste of financial resources can therefore also hinder
the progress to augment the care services by demonstrating resistance (Atkinson, 2010).

According to the RCP, which defined sustainability as an attribute of the healthcare

organisation that must get incorporated within the other domains while functioning and state
its importance by offering value additions to healthcare, not only today but also to the
patients of the future. Therefore, by definition, sustainability can be defined as the capability
or the efficacy of the healthcare organisation to offer quality care services to patients for a
prolonged period in the future (Royal College of Physicians, 2011).

However, in the present situations, the demand for healthcare services has increased a lot,
whereas a huge deficit has been observed within the economical sector (Marmot, 2008).
Moreover, hindrances from the aspects of social and environmental context also predominate,
for instance, the deteriorating support provided by the family members towards the elderly
and also the Climate Change Act, 2008 - there is a legal order to reduce the emission of
greenhouse gas by about 80% in the climate of the United Kingdom (Royal College of
Physicians, 2011). Therefore, it is comprehendible, that for the sustenance of NHS it must
take into consideration and reciprocate to the changes of all the above mentioned three
aspects (Atkinson, 2011). Moreover, scientists also debated that the healthcare organisation
should demonstrate the responsibility not only to safeguard their sustainability but also of the
whole society as well (Atkinson, 2011). With the raised clarity in this field, it has been
noticed that health of an individual or the overall populace is based on the accurate
functioning of the varied factors such as economic, the ecosystem, social and cultural factors
and most importantly the rapid access to a better healthcare organisation at the time of need
(Atkinson, 2010). Now, this whole scenario has resulted in the development of an argument
among the professionals of the healthcare setting concerning their role in the field of
education, providing job opportunities, renewing the political strength and the quality of daily
life (which includes the diet, housing arrangements, and performance of physical activity)
and also with the rapid destruction of the immediate environment (that might incorporate the
erosion of soil, the sudden incidence of flood and drought) (Royal College of Physicians,
2011).
Fig: 2 Better value from healthcare setting depends on three factors namely: Output;
Competence and Methodological strategies (Mortimer, 2018)

However, based on scientific pieces of evidence it can be stated that the hypothetical
frameworks (based on theories) offer excellent guidance to conduct better research to
progress the sustainability in the healthcare settings (Alexander, 2009). In this regard, it must
be mentioned that the hypothesis of organisational learning assists better to comprehend the
changes that take place within an organisation concerning varied context. The number of
scientific pieces of evidence on the parameters that contribute to the sustainable
improvements of the healthcare organisation is also very constrained which is considered to
be a crucial gap in this field of research (Bowman, 2008). Moreover, it is also evident that the
excellence of healthcare is dependent on the functioning of the overall system whereas not on
the skills of the individual staff members. Therefore, the theoretical frameworks help to
comprehend these factors and it also states that to accomplish quality improvement an
organisation must promote its conduct which must pave out the way for sustainable
modifications (Hovlid, 2012).

The Evidence in the Learning Organization (ELO) model – A theoretical framework

Bringing any alterations within the clinical field necessitates modifications within the
organisations and this is enhanced through organisational learning. The process helps to
create alterations within the routine whose outcomes can be calculated. This particular
framework helps the healthcare setting to "learn, create, and share knowledge about
evidence-based practices and the system issues that facilitate or inhibit these learning
processes" (Hovlid, 2012).

The four major themes that are part of this framework: inquiring, deciding, relating, and
interpreting. Overall all the four themes of this framework are necessitated by the
organisation to demonstrate the procedure of learning along with the process of partaking
more recent information efficiently (Hovlid, 2012). The steps of the model are briefly
discussed below:

Inquiring:

This step determines whether the staff members of any organisation or team are prepared to
inquire about the process of "loop learning" to make the procedure easy. This particular stage
is further divided into three other steps such as Acquiring, which determines that whether the
staff members possess the skills related to Information Technology training; Informing,
which determines that whether the staff members possess the cognitive skills related to
formulating decisions based on evidence (i.e., the EBM skills); Transforming, this step
determines that whether they possess the internal inspiration for learning (Hovlid, 2012).

Deciding:

This step determines whether the staff members are formulating an efficient process of
making decision that amalgamates the pieces of evidence with decisions of the healthcare
setting. This stage also incorporates three steps such as Deliberating, which determines that
whether staff are performing comparative analysis with newer methodologies or intending
goal for formulating better choices; Decision-taking, which determines that whether the staffs
are utilising any computer-assisted tools for synthesizing decisions; Evaluating, whether they
are up taking quantitative or qualitative analytical strategy that could calculate the results
(auditing) of the taken evidence-based decisions (Hovlid, 2012).

Relating:

This step determines whether the staff members are assisting the process of evidence-based
making of decisions by efficiently corresponding and making associations with the other
members of the organisation. Again, this stage also incorporates three different steps for
ensuring excellence such as Sharing, this determines whether the healthcare setting have a
reliable information network for the dissemination of knowledge; Cooperating, this ensures
that if the organisation have accurate functioning teams for the proper synthesis of knowledge
and comprehension; Advocating, this step ensures that whether the healthcare organisation
possesses enough methodologies that could motivate to bring about a modification within the
culture of the organisation for effective learning (Hovlid, 2012).

Interpreting:

This is the ultimate step of this model. This particular step determines whether the staff of the
organisation could effectively understand the significance of the evidence-based decisions or
the adopted innovative strategies to address their unspoken knowledge. This stage is also
conducted based on three essential steps, i.e., Judging, by this step the staffs could efficiently
judge the results of the decisions adopted and the need of the change within the practice;
Knowing, this step ensures that whether they require to formulate any new model or
framework for successful corresponding of the decisions adopted based on evidence-based
practice; Formulating, through this step, it can be determined that whether they are assigning
codes for the organisation to implement the change (Hovlid, 2012).

Therefore based on this framework four other models have been developed that clearly
explained the mechanisms of organisational learning and the crucial parameters that play a
vital role in sustaining the changes within the organisation (Refer Fig: 3) (Walshe, 2007).
Those four models are namely: Argyris' (Argyris, 1996) loop learning, Nonaka's
Socialization, Externalization, Combination, and Internalization (SECI) (Nonaka, 1994), the
framework of complex adaptive systems (CAS) and the Kim's (Kim, 1998) concept of
organizational learning (Plsek, 2000).
Fig: 3 Contributing factors for sustainable improvements within healthcare setting
(Hovlid, 2012)

In this regard, another study by Robert, et. al., 2020 have discussed varied strategies of
quality improvement within the healthcare settings. The strategy of the quality interventions
are 1) to expand the time limit that nurses spend with patients; 2) augmenting the security and
dependability of the care services; 3) enhancing the level of experience of the patients and the
staffs; 4) modifications within the physical environment which could augment the level of
efficacy (Robert, et. al., 2020). The outcome of the study highlighted that modification within
the adoption timing, execution of methodologies locally along with certain alterations within
the context had a potential impact upon the routine practice of the healthcare that eventually
developed succeeding legacies. The researchers of the study suggested that to accomplish the
prolonged sustainability via any quality interventions must take into consideration of the
continuous developing and acclimatizing nature of the changing procedures (Robert, et. al.,
2020; Dückers, 2009). The healthcare sectors are under the immense pressure of the rising
expenditures and service demands and the varied cost reduction approaches only had a
diminishing impact. In several nations varied plans have been undertaken such as the
Accountable Care Organisations whereas in the United Kingdom, the care approach is
towards the Sustainability and Transformation Plans (McClellan, 2014; Black, 2016). All the
innovating plans indicated towards certain things that the support of the clinicians, politicians
and the common masses can only be acquired if the improvement aimed towards quality and
sustainability (Black, 2017). There are significant six categories of waste in the field of
healthcare, the first one is inadequate care service, second one is absence of coordination in
between health care professionals and not offering the care within proper time, third one is
additional investigations for treatment that raises the cost; the fourth one refers to the
intricacies of administration (Black, 2017). Another waste as proposed by the Berwick and
Hackbarth is the technical inefficiency (Berwick, 2012). In response to the above mentioned
conditions, the author Nick Black suggested within his investigation that to make any
alterations or modifications successful it demands time, and the involvement of the
individuals from all sections of the society such as clinicians, politicians and the common
masses. He also added that the financial incentives should be aligned judiciously, and the
threat to economic disruption should be managed thoroughly. In countries like the UK, the
time span is short and therefore these reforms should be undertaken on an emergency basis.
The strategy of eliminating the waste will provide a new scope towards the sustainability
within the healthcare services (Black, 2017).

The NHS sustainability model should be mentioned here which has been formulated to
offer raised level of care services at diminished expenditures, to meet the persistently rising
prospects and requirements of the healthcare services (Refer Fig. 4) (Maher, 2009). There
are 10 factors concerning staff, procedures, and the issues within an organisation which all
play a significant role in sustaining the change in the sector of healthcare. The model
contributes to the process of sustainability by securing the benefits, all the resources most
importantly from the financial and human aspects (Maher, 2009).
Fig: 4 Sustainability Model by the NHS (Maher, 2009)

The rationale for the study:

As evident from the scientific shreds of evidence, many nations are facing tough challenges
to offer financially savvy and also quality health care services to the common populace and
among them, Saudi Arabia has also gone through the challenge of raised costs and below
graded quality care services to their patients or public (Walston, 2008). Therefore, as a
quality intervention, the nation had already addressed these problems with re-structuring their
healthcare settings by privatizing all the public hospitals and initiating the insurance coverage
for the common masses and also for the foreign staff members. The aspect of healthcare is
considered as a right for all people living in Saudi Arabia and it is resourced primarily (75%)
by the public whereas only 25% as an "out of pocket" expense (Walston, 2008). When
concerned about the delivery of care services in healthcare it is carried out via three main
subdivisions: the MOH network of healthcare that is distributed throughout the nations, the
private counterparts, and the rest governmental sectors. Among the challenges that are
predominant within the healthcare sector of the nation, the non-existence of educational
infrastructure that had failed to resource the desired number of healthcare professionals such
as clinicians, technicians, and nurses. The other challenges are the absence of co-ordination to
achieve the financial and human resources; escalating financial expenditures and the rapid
increase in the competitive level within the sector (Walston, 2008).
Therefore the present research study will conduct an investigation or exploration of the good
frameworks that will help to sustain the changes within the healthcare setting. The
methodological approach that will be used for conducting this research investigation will be a
mixed-method paradigm.

Research Aim:

To conduct an investigation or exploration of the good frameworks that will help to sustain
the changes within the healthcare setting.

Research Questions:
 With the utilisation of the chosen framework, whether the staff could identify the
needs for the change?
 What are the quality interventions adapted to meet those needs to achieve
sustainability in the long term?
 What the outcomes of those quality interventions in terms of the acceptability of the
staff members and achieving sustainability?

Methodology:

The literature review section had highlighted many areas that discussed the crucial factors of
the healthcare setting which demands improvement if sustainability is required. Therefore, to
assort information on the above factors and to study the efficacy of a good framework that
could address this issue research should be both quantitative and qualitative in nature. This is
referred to as the mixed-method paradigm as it will provide quantitative findings that will be
precise and can be analysed vividly and also the qualitative findings which will offer an
overall perspective on the topic and will help to interpret the findings (Terrell, 2012).
Moreover, it is already established that with the utilisation of a mixed research paradigm, a
researcher will be able to assort wide categories of findings that will assist them to formulate
a rich and accurate conclusion. According to Cohen, 2012 this methodology of utilising two
or more strategies to collect data is also known as triangulation.

Therefore a qualitative case study design will be used for the explorative research study
which will use the theoretical framework the learning theory as fundamental basics. For the
present research investigation, a purposive sampling of at least 20 members will be used
which will be addressing the issues of concern of the organisation (Yin, 2009). Therefore the
participants will be of varied functioning roles within a healthcare setting or a hospital of
choice in Saudi Arabia. For the research study, permission will be obtained from the
administration department of the hospital, and eventually participants of varied functional
backgrounds and experiences of work will be recruited for the investigation, i.e., for the
sustainable improvement project (Yin, 2009).

The evidence of case studies that will be incorporated will be initially from the
documentation form the administration which will provide an idea of the overall aim of the
sustainable improvement project and most importantly the detailed background information
of the members or the participants (Yin, 2009). A face to face interview will be conducted by
the researchers of the following participants and if not possible then a telephonic interview
will be conducted for the execution of the exploration (Mays, 1995). The time of the
interview may vary for each participant however, it will be scheduled for 30 minutes for
each. The interviewer will record the voice note of each participant for accurate transcription
afterward without allowing any bias to crop in form the side of the interviewer. Moreover, the
purpose of the interview will be to assort a wide range of information from all of the
participants and then screening and sorting the information for excluding duplication and
after achieving redundancy the investigation will be closed (Patton, 2014).

During the interview, a detailed discussion will be tried to accomplish and the interview will
incorporate basically few essential themes:

Recognition of the needs that demands change; 2) preparation for the change; 3) quality
interventions that will be utilised to impact the change; 4) exploration outcomes; 5)
acceptability of the interventions that will be used (Patton, 2014).

Open-ended questions will be asked during the interview and before the interview, the data
on the demographics of the participants will be assorted that will include the age, gender, the
professional background, their involvement towards the quality improvement work for
sustainability, tasks of a leader, and their individual experience at work at that particular
hospital (Lincoln, 1985). Thereafter categories or gatherings will be built depending on their
contribution or involvement towards the sustainable improvement projects. One group will
consist of the employees who will be directly involved within the project; and the other group
will consist of the employees who will not show any direct participation but their routine
work will be influenced by the changes.
The next step of the study is the most crucial one, the data extraction and analysis process
(Lincoln, 1985). According to Creswell, 2016 the interview documentation will be analysed
by using the following three stages: arranging and systematizing, tapering down through a
procedure named condensation and coding; then eventually demonstrating into a figure,
followed by a detailed discussion (Refer Fig: 3). A computer tool will be used to assign codes
and through the condensation of the codes will be themed will be interpreted depending on
the ELO model (Creswell, 2016).

To enhance the study reliability, validity, and credibility of the findings the analysis will be
validated with the aid of three key respondents with regard to the planning and execution of
the interventions within the hospital as suggested by Barbour, 2001. Moreover, a professional
translator will be used to translate the quotations into proper English before presentation or
dissemination of the data and the quotations will be represented without introducing any
alterations in the meaning of the quote and the confidentiality of the participants will be
maintained throughout the process (Barbour, 2001).

Ethical considerations:

Another important part of the study is the ethical consideration which will be obtained from
the Committee of the Research. The General Data Protection Rules, 2018 will be maintained
while assorting, handling, and storing the information to avoid any unauthorized access or
illegal processing of the data (Regulation, 2018). Moreover, before conducting the research
study, informed consent will be obtained from each of the participants and throughout the
research investigation, the confidentiality and anonymity of the participants will be
maintained (Nardini, 2014).

Limitations:

The researcher may face a few constraints such as information bias and confounding factors
during the investigation (Yin, 2009).

Conclusion:

The research proposal has discussed its aims and objectives to achieve sustainability with the
aid of quality interventions by following a good framework in a hospital setting in Saudi
Arabia. Therefore, it has also analysed about few theoretical frameworks which would help to
achieve the objectives. Moreover, the methodology section has detailed the plan of action for
carrying out the research investigation. The study has addressed a significant problem in
today's world especially in Saudi Arabia where the healthcare setting is facing huge
challenges to provide high-quality care services to their people because of certain causes that
have been discussed above. So for the health and well being of the mankind of the nation, this
particular research proposal has been considered that if become successful can show the path
to the other nations as well facing the same kind of challenges.

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