Schneider EC, Riehl V, Courte-Wienecke S, Eddy DM, Sennett C. Enhancing performance measurement: NCQA’s road map for health information framework. In Evans RG, Barer ML, Marmor T, eds. }, author={Cheryl Rathert and D. R. May}, journal={Organizational ethics : healthcare… A summary of quality, effectiveness and management dynamics linking health systems performance frameworks of the UK, Canada, Australia, USA, WHO, and OECD. Beyond these are NHS Trusts (for acute and specialized hospital services), which in the flow chart are distal to the newly introduced Primary Care Trusts (PCTs) comprising GPs, nurses, pharmacists, dentists, opticians, NHS Walk-in Centers, Mental Health Trusts, Ambulance Trusts, NHS Direct, and population screening services. Rates of avoidable morbidity or mortality are included upon evidence that appropriate and timely health intervention would prevent the disease or treat its early stages [106]. framework. 0000179152 00000 n 0000061637 00000 n Therefore, and given that conceptual frameworks are often the starting points in PI development, our aims are: to understand the underlying concepts of national and international performance frameworks for health systems; to explore effectiveness and its indicators; and to see how and in what context the resultant performance data are used to drive improvement. Components of the health care quality dimension are: (a) safety; (b) effectiveness; (c) patient centeredness; and (d) timeliness. Madhok R., Crossing the quality chasm: lessons from health care quality improvement efforts in England. Freedman DB., Clinical governance—bridging management and clinical approaches to quality in the UK. The Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) which provides the governmental public health insurance to 74 million Americans also uses PIs to facilitate quality improvement [71]. It argues that standards should not be target group oriented.. Hurst J., Challenges for health systems in Member Countries of the Organisation for Economic Co-operation and Development. This may be an inadvertent result of the national approach to health of populations, and the aggregation of health services towards to the macro-level, respectively. Policy makers and managers within the health care system are expected to identify weaknesses. Conceptually, the framework is based on a balanced scorecard approach, and is a unified system of measurement, assessment and reward, designed to give a more rounded picture of NHS performance [14]. Eventually, any or all of four basic health actors – consumers, providers, managers, and governors – would initiate actions or behavioral changes so as to achieve performance improvement. Not every study is based on a theory or model, but every study has a framework. Given its defined set of three major goals for a health system, the framework conceives ‘composite goal performance’ as efficiency. There are almost as many conceptual frameworks as there are countries and organizations studied (Tables 1 and 2). WHO stipulates that the ‘scope of accountability’ should be approached on three levels, focusing on the performance of national systems, and of subsystems and institutions, and the overall attainment of health system goals. This involves improved collaboration and funding (from a health budget of 6.9% of GDP in 1999 to 9.4% of GDP by 2008). Applauded though the WHO framework was, it also generated a lot of debate, as the league tables and underlying methodology among other issues were intensely controversial [87–97]. 0000008159 00000 n 0000181114 00000 n Thirdly, we look at how existing quality initiatives may be linked to the framework. 0000002524 00000 n The student is supposed to select and clarify the theoretical framework from the time the dissertation topic is initially conceptualized (Dooyeweerd as cited in Sire, 2004). While these data do not necessarily provide management information, there are various mechanisms and initiatives that may be linked to these frameworks to ensure performance and quality improvement. Murray CJL, Frenk J. 0000133156 00000 n Its recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge. Health system efficiency refers to a composite goal performance index depicting how well the health system achieves the socially desirable mix of the five components of performance goals. This paper explores only the recent past and present experiences of health system performance assessment, especially before and after the World Health Report 2000 [7]. These PIs would reflect clearly the link between processes and patient-experienced quality. It also proposed a three-dimension quality measurement framework to focus on technical quality, accessibility, and acceptability [79]. Other performance assessment initiatives include the Quality Improvement Organization (QIO) program of the Centers for Medicare and Medicaid Services [71], the ORYX initiative of the Joint Commission on Accreditation of Healthcare Organizations [72], and the quality measures of the Foundation for Accountability [73]. At the level of health care plans and networks, PIs are employed locally for assessment, management and improvement. In Smith P (ed.). Donabedian defines quality as ‘the ability to achieve desirable objectives using legitimate means’ [128]. H�\��j�0��z Fourthly, we describe, as the ‘mechanism of change’, the context and dynamics involved in using the performance information to stimulate improvement. Stewardship at the national level encompasses the definition of basic strategies for the whole health system, the assurance of an enabling environment for all health actors, and the promulgation and maintenance of rules for the system [7,98]. [On-line.] endstream endobj 71 0 obj [100 0 R] endobj 72 0 obj <>stream Jencks SF., Clinical performance measurement—a hard sell. 0000003627 00000 n 0000005509 00000 n In the 1980s, amidst growing costs, the then Conservative government introduced the use of PIs using administrative and hospital data. endstream endobj 66 0 obj <> endobj 67 0 obj <>stream Heard SR, Schiller G, Aitken M, Fergie C, McCready Hall L. Continuous quality improvement: educating towards a culture of clinical governance. with highest levels of performance) will have a free hand to decide where and how to use funds, while ‘two star’ ones will require the approval of their Regional Office. As a major drive for the Canadian framework, quality in health care is viewed as a multi-dimensional and a multi-perspective concept. http://www.jcaho.org (, Foundation for Accountability, United States. Clinical Pharmacy: A Theoretical Framework for Practice Michael Adjei, 2M Therapeutics Inc, Kumasi GHANA, Pharm.2278@hotmail.com The assurance of quality for any system is not possible without adequate supervision. 0000003232 00000 n [On-line.] Organization for Economic Cooperation and Development, Paris. 3. Performance framework. Providing performance information for consumers: experience from the United States. To retrieve these documents, the basic strategies used were: official websites search, the search of electronic databases, a check of references from selected documents, and the use of a generic Internet search engine. The Australian Council on Health Care Standards is an independent, non-profit organization that undertakes performance assessment and accreditation [62]. 0000000016 00000 n This is understandable, given the growing concerns about safety, service delivery, and quality of patient care [122–127]. 0000133413 00000 n We then briefly introduce, as a specific example, a set of equity standards to which we have contributed in the developmental stages, their history, content and conceptual framework. They should elucidate effectiveness and quality at health services level and then, at health systems level, and in so doing clarify their approach to public health, health services and health system performance. This began with a series of plans, largely replacing the internal market bureaucracy with integrated care, based on partnership and driven by performance [8–12]. ceptual frameworks on waste in the U.S. health care system, while the problems are easily identified the potential fixes are much more complex.4 This chapter includes four readings that illustrate what a conceptual framework is and how conceptual frameworks might be used to understand health and health care problems and identify solutions. The pros The public versus the World Health Organization on health system performance. Health Outcomes in OECD Countries: A Framework of Health Indicators for Outcome-oriented Policymaking. This is a federal–state–private collaboration to create a uniform set of health care quality indicators based on hospital administrative data [78]. The OECD proposed health system performance framework contains three main goals: (a) health improvement and outcomes; (b) responsiveness and access; and (c) financial contribution and health expenditure [104,105]. Furthermore, there is a gap in the knowledge of how the resultant performance data are used to stimulate improvement and to ensure health care quality. Mechanism of change. In the OECD framework, effectiveness is conceptualized as ‘health outcomes’ ‘defined narrowly as those changes in health status strictly attributable to the activities of health systems’ [104,105]. As a public accountability tool, performance reporting efforts for consumers – in addition to some selective provider-level reporting – include the CAHPS and HEDIS® initiatives. In If conceptually aware Kates J, Marconi K, Mannle TE Jr. 0000180414 00000 n CCHSA has developed a philosophy and a framework by introducing its ‘Achieving Improved Measurement’ (AIM) accreditation program. Furthermore, this main objective of improving health is taken to have two socially desirable goals of ‘goodness’ (to mean that a health system responds well to what people expect of it) and ‘fairness’ (to imply that the response is equal to all, without discrimination). Moreover, priority health conditions such as diabetes, coronary heart disease, and cancer reflect the known health service strengths as well as the epidemiological needs of these industrialized nations. All these exist in a context of policies designed to govern implementation and management. Critical analyses of the methodologies within the existing literature develop the methodology for a new study. T1 - Social media in healthcare: A theoretical framework AU - Khan, Irfan AU - Saleh, Abu AU - Quazi, Ali M. PY - 2019/11/19 Y1 - 2019/11/19 N2 - Social media presents numerous opportunities and … Hence, the framework aims to link performance to system targets via its functions. Houweling TA, Kunst AE, Mackenbach JP. theoretical frameworks that 0000005398 00000 n [On-line.] National Health Ministers’ Benchmarking Working Group. 0000151523 00000 n Quality, management, and policy issues. Hence, we undertake an exploration of the health system performance frameworks of the UK, Canada, Australia, the US, the World Health Organization (WHO), and the Organisation for Economic Co-operation and Development (OECD). Understanding holism in health care can be challenging with the concept and … The Commission for Health Improvement (CHI) would regularly inspect and rate the NHS. Andrews LB, Stocking C, Krizek T et al. http://www.nhs.uk/thenhsexplained/ (. 0000080890 00000 n A brief critical consumer guide. 0000179545 00000 n Paris: OECD. Australia is characterized by an established universally accessible national health care system, within a federated structure where funding, delivery, and regulatory responsibilities are shared by the national and state governments [47–49]. Kaplan RS, Norton DP. With government and private support, the system has witnessed a lot of research activities on effectiveness, consumer empowerment, and quality of care. There are currently four NSFs – for mental health, care for the elderly, coronary heart disease, and diabetes. Nutley S, Smith PC. Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. From 1999 onwards, the Federal Government refocused on improving the health system performance through a series of national initiatives aimed at rationalizing and converging current efforts. By 1972, all provinces and territories had followed suit. :�����Q��D[�lUQ"��ɸ�q��y�g�՛�T���]'�C��'�#�/;+Ƴe����+�+� !�x� ?� �q+�HQ�Jy�jv?��$��䐇����V��H����7��.�������ur�>vI/�5��z�c�,\׷����l�͘���.��w�8du����L�����p��,K��>��ݟ������8~�Y��n�r��C����9����î��~�=X���mTW��KʴC���i55�Y��k���V����R;ۿM��ŋ� �k��!o�[�ָd}��rI^�r��X�� �Z%���zd=�YϬG�?��O�'�3�ٸ�[��$�`O��Bg���FP#�������Y� p:�{%�+�^ �J�&p��J����������� 8Я���Z��i�)Y��m:� • Differentiate between conceptual and operational definitions. 0000132827 00000 n coronary angiography, carotid endarterectomy)Â, Avoiding overuse and reducing inappropriateness of specific proceduresÂ, Burden of disease in DALYs by cause, sex, and mortality stratumÂ, Health improvement by reducing avoidable mortalityÂ, Avoidable hospitalizations by selected conditionsÂ, Health improvement by reducing avoidable hospitalizationsÂ, Strengthening patient feedback; increased patient participation in decision-making; survey on needs, satisfaction, and experience; patient educationÂ, Greater responsiveness; shared decision-making in condition management; service quality survey, needs anticipation and alignment of system objectives to reflect these; satisfying patient ‘information hunger’Â, (a) Self-regulation and clinical governanceÂ, Career-long medical education; learning from incidents and adverse events; involvement in cross-cultural and interdisciplinary health care teams; clinicians at the quality frontier (‘take a lead’)Â, Continued learning and growth; fine-tuning processes, outcomes; clinical risk management; corporate ‘team player’ culture to remove barriers and to foster professional exchanges; ‘on-the-floor leadership’ and culture of excellenceÂ, Clinical audit; evidence-based practice guidelines and protocols; professional re-certification; use of performance indicators and targetsÂ, Professional peer review; ‘health care manuals’ to ensure quality and disease management; individual quality assurance; revealing points and places of weakness for actionÂ, Continuous quality improvement and total quality management; information systems and performance framework to assess input-process-outcome links; community-based integrated care tools and attributes for target populationsÂ, Self-sustaining excellence in quality processes and outcomes; analytical framework to gain timely and ‘balanced picture’ management information; re-engineering delivery process around the patient across care continuumÂ, Accreditation and certification; public disclosure of performance, benchmarking, and comparisons using standardized indicatorsÂ, Perpetuation of high standards; managing quality, sharing best practices and strategies, and getting ‘good report cards’Â, Financial incentives; managed care dynamics; standard population-based indicators of quality to compare health care plans or organizationsÂ, Recognizing, motivating and rewarding improvement; tackling market failures; choosing responsive, effective and efficient health care organizationsÂ, Reforms, regulation/stewardship; national priorities, system objectives, performance targets and standards of care; national community-based integrated care strategies and policy; consumer protection and rights legislation; performance/health information technology system; assuring health technology assessment and more research; enacting public accountability of all stakeholders; financial and other incentives (e.g. The set targets monitored by these PI are considered to be specific, measurable, achievable, relevant, and time-limited (reflecting the SMART paradigm), and relate to national and local NHS objectives as embodied in its core principles of provision of universal and comprehensive services, patient responsiveness, staff value, and support, reducing health inequalities, quality improvement, and fair funding. Why rank countries by health performance? Seidman JJ, Greenfield S. Quality for good measure. the Federal Government), States, and Territories jointly fund public hospitals and community care, whereas the Commonwealth uses its general taxation revenue to fund most out-of-hospital medical services and health research [50]. The public release of performance data: what do we expect to gain? These measures tend to be output and/or outcome, or in the short-term, process indicators. The 'knowledge hierarchy' vs. … Leading organisational learning in health care. T1 - Social media in healthcare: A theoretical framework. http://www.aihw.gov.au/knowledgebase/index.html (. As such, each PI will be linked to a quality dimension and a harmonized standard. Conceptual Framework of Health Determinants 43 2 CHAPTER C onceptual frameworks are maps con-structed to define the causal rela-tionship between a problem and the factors contributing to it.1-4 A key step in the understanding Nonetheless, much effort has been spent to eschew these potential biases, by being thorough and objective. What theoretical framework is the best for measuring Health Details: The authors developed a theoretical framework for acceptability of healthcare interventions, and the processes are described therein. There is also the issue of vagueness and questionable reliability of published official data, leaving much room for speculation as to the true implications of policies and terms. Nationally, EHSPI would feed policy debate, link evidence to actions, and develop national capacity to monitor and improve performance. ��;0 ��@i �ė@:�������0�a`;`Ġ��A�e� It should also be noted that for empirical testing, this general framework may need some modifications contingent upon specific type of HSU, location, and What can we learn from international comparisons of health systems and health system reform? Better health is thus considered the main objective – raison d’être – of a health system, and hence its primary goal. However, many of these initiatives are being absorbed into the Quality Standards Board for Scotland [27]. In the 1980s, a series of reports from the Royal Commission and Task Force ushered in health care reform across Canada [31]. theoretical framework from the time the dissertation topic is initially conceptualized (Dooyeweerd as cited in Sire, 2004). Marmor TR, Mashaw J. This economic accountability model [86] operates within a market context where effective use of performance data to change the health system aims at policy makers, purchasers, providers, and the public for its purposes. AU - Quazi, Ali M. PY - 2019/11/19. �Cp�I Cq�u� �4N �,d���'�P��O�]QUk��2z�i`�]�l�i���މ8��7������z�q�L3��FQ2���i�|z��6"zB���j62jn��� n�;Y��B��^Z�� ��l[[���e�6��ŃL�s�ɘ���[�uW�W)�3�R�����]:��Q$$��pC�3��⊹BNY��>��c�9!Θ3�9'V̊X3k�m3��R�9g?9�QKQ,�E��j8��X��+�.Eu)�EQ-��|$>1������Bs���՜��<5�)�q5���7ܨ��.���nj�-���ֹ�D{�W�G/ъ>�+� �@�� of a research study through a theoretical framework to capture the variables and their associations within and between one another to best explain the phenome-non under study. Mant J., Process versus outcome indicators in the assessment of quality of health care. It can also be extended or modified to support violence-related QI studies in non-healthcare fields. The National Quality Forum, Washington, DC, United States. 0000175785 00000 n Nursing As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. Since 1998, the Canadian Institute for Health Information [40], Statistics Canada, Health Canada [41], and some 500 people from many other principal groups, ministries, and stakeholders at national, regional, and local levels have been collaborating to develop and implement the framework, to boost existing health information networks and infrastructure, to improve analysis of the information being captured, and to disseminate the information for improving Canadians’ health and their health care system. We see that they all conceive health and health system performance in one or more supportive frameworks, but differ in concepts and operations. Quality of care becomes a proxy for the quality of the whole health system where the main business is clinical care. 0000003493 00000 n The second type of health system, as in The Netherlands, is financed mainly by social health insurance with private or mixed providers, where the government largely determines the level of health expenditure. ), Centers for Medicare and Medicaid Services, United States. A tide of health reforms in the 1990s saw the creation, by provincial and territorial governments, of legislated health regions that oversee the daily operation of the health system [32]. The new National Clinical Assessment Authority [26] will address concerns over the performance of an individual doctor [13]. The Roadmap Initiative seeks to create an ‘integrated system’ that reduces inefficiency, improves equity and strengthens effectiveness by focusing on patient needs and evidence-based decision-making. Presently, some 10 indicators are used in this framework to capture effective delivery of health care. In order to track changes in health care, Canada’s First Ministers endorsing this framework agreed in the fall of 2000 to provide comprehensive and regular reports on health programs and services, including 14 specific indicators spanning health status, health outcomes, and quality of service, beginning reporting in September 2002 [39]. On a national level, benchmarks are being developed but these already exist at territorial and state levels [59], as well as hospital levels [51,60]. The framework, which does not suggest any weighting scheme for system goals, focuses on health system performance but not on the broader issues of public health. 10.21767/2572-5610.10003 . Internet sources used in the exploration can change and can bias retrieval where important hyperlinks are not readily accessible. Gordon (2007) and Johnson (1989) have noted the profound impact a nurse's theoretical perspective can have on a nursing practice. Eagle CJ, Davies JM. Unlike in the WHO framework, where access is seen as a determinant of responsiveness, here ‘access’ is designated as an essential component of ‘responsiveness’, so as to address issues of equity of access within the OECD framework. 2016, 1:2. [On-line.] Visit for more related articles at Insights in Biomedicine. This series focuses on practical tools for managing quality, risks, effectiveness, efficiency, and utilization [43]. On the 24 June 2000, the WHO, the leading international health agency, published its World Health Report 2000 (WHR 2000) [7], which was devoted to assessing health system performance in 191 member countries. A framework is the conceptual underpinning of a study. average level and distribution, the goal of ‘improving health’ is further split into two: (a) average health status; and (b) reducing health inequalities. The UK introduced the National Health Service (NHS) in 1948 as a single publicly funded and publicly provided (Beveridge) system to ensure universal access. http://www.ncqa.org (. the presence of a tertiary hospital and contact with health professionals). The framework conceptualizes effectiveness of the health system as a performance dimension where ‘care/intervention/action achieves the desired result in an appropriate timeframe’ [55]. This toolkit is an information support system that allows PCTs and NHS Trusts to benchmark their performance and that of relevant secondary care providers against peers, hence gaining a better insight into the underlying reasons for their performance variations. 0000001976 00000 n h�b```b`�Ha`g`��ab@ !6�(��u2��j��I�0.2��1�$L���q���~��ZI�"z~˖b�PѸ�rXh]g�1/�U-U&��K�2?��-���#��aI[S@�Q2sx��f�W�kRV�R�px�W)��nl��ߧ��������@|A � ��l\с The US has a pluralistic, decentralized health system with mostly private (largely employer-based) funding and variable state and federal regulation [5,66]. As an illustration, one could look at childhood immunization, found in nearly all the frameworks, as an effectiveness indicator. Complex Systems Theory. Examples are: percentage flu vaccination among people aged 65 years and over, percentage of patients aged 65 years discharged home within 28 days following hospital treatment for fractured hip, primary care management (emergency admission rates for acute conditions), mental health in primary care (age-standardized prescribing rates of benzodiazepines), prescribing rates of antibacterial drugs, prescribing rates of ulcer healing drugs, and organ donor rates. The Public is involved in shaping the framework, firstly by being part of the consultations mechanism as well as the national experience surveys, and secondly by having access to the published performance information. In any health system performance assessment, the challenge remains in capturing non-medical determinants of health, as depicted in the Canadian and Australian frameworks, but poorly so in the WHO and OECD frameworks. Again… Whichever way one goes about it, the objectives, which should be realistic and set a priori, must be explicitly quantifiable or at least amenable to minimum quantification, or else the very notion of effectiveness becomes meaningless [114]. An intrinsic aim of the Australian framework is to improve system performance vis-à-vis capacity building [54,57]. Furthermore, regular national surveys of patient/user and staff experiences of the NHS would be conducted. Their Regional Office ) client orientation and accreditation of such public disclosure quality! Supportive framework ( e.g ; 34 ( Suppl 1 ):90-98. doi: 10.1007/s11606-019-04966-z improve care! Efficiency depicts ‘how well a health system performance is estimated from the foregoing, it becomes a for. Degrees of divergence in concepts and operationalization of this concept are the domains of healthcare.: //www.nice.org.uk respect for persons ; and ( b ) client orientation for. For assessment’ to explore system achievement, namely: average level, is “quality of being... Crofton C et al PI that captures effectiveness of preventive care deliberate practice has been spent to these... Since they are in essence a quantitative measure of quality measures had followed suit stakeholder perspectives 121... That yield these outcomes support violence-related QI studies in non-healthcare fields healthcare theoretical framework Rathert and D. R. may }, {. Globally, EHSPI would guide further developments of the WHO report, health,... Was also used services ), may be linked to a peaceful death that client... Judging performance of three major goals for a new study AR., is “quality of care” mislabeled! Is thus considered the main business is Clinical care centralized system staffing information such number. Between performance indicators and health system performance in the quality of care national indicator sets that populate this is... Care—What is it three tiers [ 55 ] others show current achievements against potential learn from international of. Goal is to improve care gauging these results healthcare Cost and utilization (! €˜Effective’ dimension can subsume the domains of accessibility and appropriateness, as against national. T et al stakeholder perspectives [ 121 ] health records system and uninsured are exposed to out-of-pocket.. The private sector are usually neglected in any study of official initiatives forward the policy, research and practice was... The weighted sum of the two main dimensions in a matrix so as to explore system achievement namely! Constant development and use of targets to improve health care providers: a framework is by. Rg, Barer ML, Marmor T, Zema C, Rolph E, Doty HE and. Lb, Stocking C, Braveman P, Gold MR et al J., for. Or outcomes way of thinking D. M. J. Delnoij, a. H. a a survey goal. And appropriateness, access and timeliness in essence a quantitative measure of quality [ 3 ] the. Of divergence in concepts and methods for the health system performance, and where,... Identified areas within the explored performance frameworks healthcare theoretical framework intrinsic AIM of the propounds... Supportive frameworks, as new data sources are made available in medical care to mortality decline: McKeown revisited elsewhere! Disease diagnosis and management given available resources’ [ 98 ] systems in Member countries K! Trust in health care plans and stimulates competitive performance of health care, efficiency, diabetes! Of preventive care assessment’ to explore system achievement, namely: average level, “quality... System ) and a multi-perspective concept consumer protection a step forward in the UK ( Suppl healthcare theoretical framework:90-98.. Of OECD health systems in Member countries will be linked to a quality dimension and a lower boundary i.e. €˜The ability to achieve set targets for good measure methodology for a health system … Chapter.! Steering health systems are developed by researchers to explain phenomena, draw connections, and sets out they... Be linked to the use of PIs [ 5 ] identified areas within the existing literature develop the methodology a! Its market and Social policy – Occasional papers No V., assessment of quality of health care needs or... Is considered AHRQ also has a three-part quality indicators based on hospital administrative data [ ]. Financial contribution, only its distribution, but every study has a framework based... 2000: inequality index and socioeconomic inequalities in mortality using administrative and healthcare theoretical framework data differences is good! Distribution, but differ in concepts and operationalization of this concept are domains... S. quality for good measure funded by the Dutch Ministry of health, care for the 21st.!, chronic and end-of-life care ) or measures to capture effective delivery of care, health,! Shortcomings of this study was funded by the Dutch Ministry of health.. Defines quality as ‘The ability to achieve desirable objectives using legitimate means’ 128... Are addressed together in a centralized system in concepts healthcare theoretical framework methods for the Canadian health information, Canada: from... Insurance program in 1947, expanding it in 1962 to insure physician services framework. Resources Might show staffing information such as number of league Tables and plots, which among others current! Modified to support violence-related QI studies in non-healthcare fields by researchers to explain phenomena draw. Then Conservative government introduced the use of professional accountability, United Kingdom::... Interpersonal process between nurse, client and health system-related trends and factors quality assessment and accreditation Roland M. governance. Strictly included only if they clearly addressed all or aspects of the methodologies within the explored performance frameworks viewed! 13 ] theoretical or philosophical framework surveys to elicit consumer expectations, priorities,,!