In our example of a process evaluation for breast cancer screening program, you consider three questions; who was invited, who turned up, and the experience of those who attended. But what else is important and the value to patients and to the system? When dealing with matters as complex and intricate as providing health care or public health interventions, how do you ensure you're speaking the same language as your colleagues or examining the same themes? How do you make sure that your approach is comprehensive and that you don't miss things out? Well, the answer is that you can use frameworks. Let's find out more. Over the last 20 years, the word quality has become commonplace in health systems. If you ask any politician, decision-maker, policy specialist, or patient, they all want better quality, but what does this actually mean? I'm sure that most of you will have been in contact with your family practice or primary care doctor over recent years. In the United Kingdom, we call family practitioners general practitioners or more commonly GPs. Of the following, what's the most important factor for you in deciding whether or not you think you received a good service from your GP? Collectively, these six questions relate to six domains of quality in health care. Safe, effective, patient-centered, timely, efficient, and equitable. A high quality health system or transaction can be measured across these domains. Now, the first four safe, effective, patient-centered, timely are more pertinent to you as an individual. But as public health experts, we're also interested in the final two questions, efficient and equitable. These are more focused on the system. The US National Academy of Medicine, previously known as the Institute of Medicine, has my favorite definition of quality. The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. There were quite a few different approaches and frameworks that can be employed. In England's National Health Service, we have a slightly simpler set of domains, safe, effective, and positively experienced. So if I say safe, you can choose your quality framework based on your personal preference, what's being used elsewhere in your local system, or for any other reason you can justify. But let's pivot back into how this is relevant to evaluation. You may be asked to perform an outcome evaluation on health care intervention, a health service program, or perhaps an entire health system. The quality frameworks we've described here can help you design that evaluation. You may want to ask questions and select Indicators that cover all of the domains in your framework. We really should build evaluation in from the start from where designing a project. Unfortunately, it's pretty common for evaluation not to have been built in from the start, which means you'll commonly be coming to the project towards the end or even after it's concluded. Thinking about evaluation can be incredibly helpful when designing an intervention. For example, thinking about your key performance indicators can focus the design on delivering outcomes. When you know you're going to be measured, you're probably more likely to think about the future. So why don't smart people build evaluation into their projects from day one? Well, almost anyone working in health systems or public health will have come across evaluation at some point in their career, so it's definitely not about awareness. People in all fields of policy and practice are often scared of evaluation. They believe it requires expert knowledge, they don't have time or resource, or they fear that their team will be disadvantaged if that project is found not to work. In public health, some of these anxieties are even more pronounced. We're often seeking to implement complex, multi-faceted interventions, which are difficult to measure, or where effect is difficult to attribute. It's often very difficult to demonstrate something that hasn't happened as is the case and effective prevention, and our impact is often many years into the future. It's true that evaluation is resource intensive, it can threaten future work, and sometimes, it's very difficult for us to demonstrate a fact, but none of these are good enough reasons to avoid evaluation. I hope you'll agree with me that it's unethical for us to continue to pour scarce resource into interventions that actually don't work. So we've talked about quality and how we can measure it in health care. We've also taken a minor diversion to examine some of the reasons that evaluation is conveniently missed in health intervention development and implementation. Later, you'll look again at the different types of evaluation, and in particular, you'll look at how health care can be evaluated using the quality framework from the US National Academy of Medicine.
