Abstract
Aim
To identify health economic evaluation competencies to guide quality improvement (QI) practice and education in Ireland.
Methods
A parallel mixed-methods design was used. A rapid review profiled the focus (cost containment, efficiency and/or equity) and purpose (education, assessment, health system improvement) of health economic evaluation competencies used in healthcare education and management. In parallel, surveys were sent to senior healthcare leaders (N=528) and quality and healthcare management scholars (N=286) in Ireland. These examined knowledge, skills and experiences of using health economics in managing quality and safety, and the perceived usefulness of proposed competencies. Descriptive statistics were generated. Literature and survey findings were integrated to refine the competencies.
Results
Of the few competencies available from the literature, most had a multiple focus and purpose. Yet, none were focused on equity and few were used to assess competence. Of 189 survey respondents, few had received training in health economics (25%) or been involved in measurement of healthcare costs (34%), value for money (29%) or budget impact (23%). Barriers were terminology and inadequate infrastructure for linking clinical and financial data. Most (90–95%) endorsed the usefulness of proposed competencies. These were refined to form four major competencies: (1) understand the relationship between cost and quality in healthcare, (2) assess the basic costs and outcomes of a QI initiative, (3) understand and apply cost-effectiveness analysis to QI initiatives and (4) advance capacity for improvement by applying cost-effectiveness analysis to decision-making. Each major competency had four to six sub-competencies.
Conclusion
Health economic competencies should be integral to healthcare professionals’ and managers’ education and professional development.
Keywords: Quality improvement, Quality measurement, COST-EFFECTIVENESS, Health Equity, Health professions education
WHAT IS ALREADY KNOWN ON THIS TOPIC
Application of economic thinking in quality improvement (QI) practice and health professions education is rare.
WHAT THIS STUDY ADDS
Identification of health economic competences to guide the QI practice of frontline healthcare workers and senior healthcare leaders, and health professions’ educators.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Use of the competencies by practitioners and educators may promote enhanced systems and critical thinking about the value of selected QI activities, and their impact on patient, staff and systems outcomes.
Introduction
The practice of assessing the costs and outcomes of quality improvement (QI) initiatives is not a widespread activity.1 Skills in health economic evaluation are important for prioritising activities, yet often do not form key curriculum components in quality and safety programmes.1 Since the inclusion of QI as a curriculum topic in the WHO Patient Safety Curriculum Guide,2 several health systems in countries including Canada,3 Australia4 and the UK5 have refined their safety competencies to include QI activities. In Ireland, the Health Service Executive (HSE), that is, the management organisation of the public health system, first published QI competencies to guide education and practice in 2017, followed by refinement in 2024 as part of broad safety competencies.6 7 This refinement took place, in recognition that post the COVID-19 pandemic, there are increasing concerns about cost-effectiveness and the fair distribution of outcomes from QI work.8 9 It was recognised that despite United Nations Sustainable Development Goals targeting access to quality essential healthcare services,10 the trade-off between efficient and equitable distribution of QI outcomes is rarely considered.11 Additionally, that economic literacy among educators of health professions to address this knowledge and skills gap is not yet sufficient.12
Health professions educators recognise that economic thinking is required to demonstrate accountability and transparency for decisions,13 and that assessment of relationships between costs, outcomes and alternatives is essential.14 Incorporating economic thinking into QI educational pedagogy is imperative. In Ireland, a scoping review found that none of 43 published QI initiatives conducted between 2015 and 2020 in the Irish healthcare system aimed to improve equity. Additionally, less than 20% of the QIs provided estimates of costs or savings.8 The findings concur with other studies which suggest QI practitioners experience challenges in demonstrating the business case for improvement.15
There is international recognition that the management of quality and safety at clinical, organisational and national levels should be informed by health economic principles.16 Guides to incorporating economic evaluation in QI have been published,1 yet health economic principles have not yet been integrated into competency frameworks for quality and safety, which guide both educators and practitioners.
Methods for health economic evaluations (HEE) provide a framework for the assessment of costs and outcomes. They can be used to assess whether a QI initiative has potential to (1) reduce resource use and costs, (2) avoid unnecessary resource consumption or (3) justify additional resources.1
Traditionally, health economists have used cost-effectiveness analysis to focus on efficiency in resource utilisation, but recently equity aspects have been integrated into economic evaluation frameworks.17 The driver is to promote distributional justice in health and avoid maintaining or widening inequalities among patient groups.17 Within the QI context, the term health economic evaluation may be understood as a way to help practitioners understand the additional costs and benefits and how they may be distributed among patient groups to promote effective and just healthcare.18
In the Irish health system, concerns about value for money, inequities in health outcomes and capacity constraints persist alongside a two-tier public/private hospital system and a lack of universal primary care entitlements.19 It is not known whether senior leaders and frontline workers consider health economic competencies as relevant to their roles in managing quality and safety. Nor is their existing level of training and use of health economic methods well-documented. Addressing this information gap is important in order to design competencies that are relevant, tailored and helpful for supporting efficiencies and much-needed equity-focused QI work.
A team of QI and Health Economic educators and researchers conducted the study. We aimed to identify HEE competencies that could inform the development of national level quality and safety competencies.7 Our objectives were to:
Undertake a rapid review of HEE competencies in the literature.
Conduct a survey of senior healthcare leaders (SHLs) and frontline healthcare workers (FHWs) about their knowledge, skills and experience of using health economic methods.
Assess the perceived usefulness of proposed HEE competencies for quality and safety management.
Refine a set of competencies for FHWs and SHLs based on study findings.
Methods
A parallel mixed-methods design was used.
Rapid review
The review aligned with much of the guidance from the Cochrane Rapid Reviews Methods Group20 and was required to inform the direction and development of new competencies, alongside the survey research below. The rapid review research questions were developed in consultation with members of the HSE Quality and Patient Safety Team, who are the Research Knowledge Users. A library information specialist was consulted in the development of the search strategy and search terms. Search terms included ‘healthcare professional’ or ‘healthcare manager’ (population), ‘health economic competence’ (intervention) and ‘university, training or education’ (context) (online supplemental file 1). The search covered articles published from 1990 to 13 September 2022. Databases included Ovid Medline (all), Health Business Elite, Emerald, Embase and Scopus.
Inclusion criteria were English language papers that covered health economic competencies as part of the management of quality in healthcare. Exclusions were papers describing how to perform an HEE in contrast to discussing relevant health economic competencies. Papers which focused on leadership, advocacy, business management and entrepreneurial competencies were excluded.
Abstract screening was conducted by two reviewers (SEM and LH). A pilot of 30 abstracts ensured consistent application of inclusion criteria. 20% of abstracts were double-screened and the remainder were screened by one reviewer. Both reviewers screened the full texts, drawing on the wider team (JOM, PL and JS) when required. For full texts excluded, a third reviewer (JS) confirmed the reasons.
One reviewer (SEM) conducted the data extraction, using an agreed ad hoc template. This included the author, year, country, the title of the health economic evaluation competency, the authors’ list of health economic evaluation competencies (if specified), the competency purpose (ie, education, assessment or health system improvement) and relevant findings. Once the final list of health economic evaluation competencies was identified, author SEM categorised these according to their focus (ie, cost containment, efficiency and/or equity). These categorisations were both iteratively derived from the terminology used in extracted papers and deductively derived from existing literature.1 8 ‘Cost containment’ was defined as the control of health expenditures without compromising quality, ‘efficiency’ as optimal resource use for maximum possible health benefit in population health and ‘equity’ as the just distribution of resource and benefits across population groups. To aid study rigour, second reviewers (JS and PL) checked the extracted data and interpretation for completion and correctness.
Survey of SHLs and FHWs
Survey development
An online questionnaire aimed at SHLs and FHWs was developed to measure experience of, and attitude towards using health economic methods in managing quality and safety, and perceived usefulness of a set of HEE competencies. The survey instrument was developed in an interactive iterative process by the authors. The content of the survey questions was largely influenced by the authors’ prior experience of developing and publishing a book chapter on how to incorporate health economic evaluation in QI projects.1 For example, the set of HEE competencies included in the survey aligned with guidance from the book chapter.1 However, the book chapter was not informed by survey research with the target population, and the survey was required to tailor and inform new up-to-date competencies to inform future educational content and methodologies, using a robust approach.
In the survey, we defined health economic methods as:
tools for examining the cost and outcomes of healthcare interventions, which enable assessment of value for money and considerations of what initiatives are worth adopting or spreading more widely.
Health economic competencies were defined as:
the knowledge, skills and behaviours considered important for comparing the cost and health outcomes of quality and safety initiatives to inform decision-making in healthcare.
Six proposed health economic competencies included in the survey were based on literature.1 Prior to administration, the survey was piloted among a group of QI practitioners and health economists.
Survey administration
Participation was voluntary and anonymous. In June 2022, the questionnaire was administered using SmartSurvey to SHLs (N=529) in the HSE in Ireland. SHLs were defined as clinical directors, directors of nursing and midwifery, quality and safety leads and senior healthcare managers (ie, business, operations and directorate managers). HSE gatekeepers first distributed the survey to group level staff in each of the four professional areas, and this group subsequently distributed the survey to hospital and community healthcare organisation level participants. Reminders were applied.
In November 2022, the same survey was sent to 283 postgraduate scholars at the Graduate School of Healthcare Management, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences (n=229) and Royal College of Physicians of Ireland (RCPI) (n=57). These were undergoing Master’s programmes in Quality and Safety in Healthcare Management, Healthcare Management, and Leadership and Innovation (RCSI) and a certificate programme in Leading Quality (RCPI). The purpose of the survey was to capture views of FHWs. These were defined as doctors (eg, hospital consultants, general practitioners), nurses (eg, clinical nurse managers, advanced nurse practitioners), allied health professionals (eg, pharmacist, psychologist) and quality managers (eg, complaints manager). Surveys were administered prior to scholars undergoing health economic relevant modules and QI dissertation work.
Data analysis and integration
Responses were analysed using Stata V.18. Across surveys, descriptive statistics were generated for those identifying as SHLs and FHWs. Text responses to open questions were analysed to form themes. Survey and rapid review data were integrated at the findings stage to refine the original competencies according to the surveyed population’s needs. The research team met to discuss and draft new competencies based on the overall study findings. Key questions discussed among the team were what levels of staff the competencies should be tailored to, and what new emphasis needed to be given to content areas, not heretofore considered by the research team. To ensure the competencies would fit with the strategic direction for the overall HSE Quality and Patient Safety Competency Navigator,7 we presented the draft study findings and competences to the external Navigator development team to test their feasibility and acceptability on multiple occasions. Feedback and thoughts exchanged helped the research team to refine and produce the finalised list of competencies.
Results
Rapid review of health economic evaluation competencies
The search found 1010 paper titles after removal of duplicates. 48 titles remained after title and abstract screening and seven were relevant for full-text review (online supplemental file 2).
Data were extracted from the seven articles as detailed in online supplemental file 3. The data were then interpreted and summarised (table 1). The studies identified broad interest in developing health economic competencies and were primarily based in the USA.
Table 1. Focus and purposes of health economic evaluation competencies and study findings from rapid review.
| Author | Study aim | Focus of HEE competency | Purpose(s) of competency | Findings/outcome | ||||
|---|---|---|---|---|---|---|---|---|
| Cost containment | Efficiency | Equity | Education | Assessment of competence | Health system improvement |
|||
| Nagle and Aakus21 | Prepare trainees to deliver high-value and cost-conscious care in haematology | ✔ | ✔ | X | ✔ | ✔ | ✔ | Didactics not sufficient to change practice. Need to enhance the effectiveness of the clinical learning environment. |
| Weiner et al22 | Provide a guide to gain competence in ACGME neuroradiology milestones on healthcare economics | ✔ | ✔ | X | ✔ | ✔ | ✔ | A study guide for fellows to gain competence in the ACGME neuroradiology milestones on healthcare economics was produced. |
| Prober et al23 | Describe a pilot curriculum experience: ‘teaching HE milestones to radiology residents’ | ✔ | ✔ | X | ✔ | ✔ | ✔ | 100% of survey respondents agreed the pilot met its objectives. Online learning has the potential to address HE milestones. |
| Bulawayo et al26 | Needs assessment among health service organisations by University of Zambia | ✔ | ✔ | X | ✔ | X | ✔ | Most (93%) performing HE roles were not trained. For adequate prioritisation, need HE competencies. |
| Jacobs et al27 | Profile training needs and supports for evidence-based decision-making among public health workforce in USA | ✔ | ✔ | X | ✔ | X | ✔ | Competencies with largest training gaps included economic evaluation. Tailoring of training and resources is important for competencies difficult to master. |
| Platt et al25 | Survey opinions of nursing administrators about HE competencies for degree nursing programmes | ✔ | ✔ | X | ✔ | X | ✔ | Higher-ranked competencies tended to be practice-oriented. Those that received relatively lower ratings (still high in absolute terms) were theoretical. |
| Platt et al24 | Develop essential HE competencies for baccalaureate nursing students | ✔ | ✔ | X | ✔ | X | ✔ | Incorporation of HE into nationwide standards of education, and professional competencies, will enhance capacity to deliver high-value affordable healthcare. |
Cost containment: controlling health expenditures without comprising quality. Efficiency: optimal use of resources to achieve the maximum possible health benefit in population health. Equity: just distribution of resource and benefits across population groups. ✔=indicated, X=not indicated.
ACGME, Accreditation Council Graduate Medical Education; HE, health economic; HEE, health economic evaluation.
All of the studies’ competencies were focused on efficiency with an explicit or implied focus on cost-containment. None of the competencies had a focus on improving equity. The competencies had a multipurpose, mainly education and health system improvement. Yet, few were used to assess competence in health economic evaluation. For those studies related to post-graduate medical training bodies, the Accreditation Council Graduate Medical Education core competency of ‘systems-based practice’ (ability to analyse and improve the system of care) was a driver for proficiency in health economics.21,23 Across these papers, common competency purposes were to guide education, assessment and value-based healthcare reform.21,23
The university-led competencies for nursing students were for educational purposes to equip nurses for cost containment, that is, to lead essential change in the delivery of high-value affordable healthcare nationwide.24 25 The main rationale for public health workforce competencies was to promote effective education and training and strengthen health organisations and systems.26 27
Overall, studies indicated that health economic evaluation is an important competency but that traditional didactic teaching or online learning methods alone are insufficient to effect change in practices. There appeared to be a scarcity of qualified faculty and practice role models to aid delivery of these competencies, and a lack of a common language around the topic.
Survey of the knowledge and skills of SHLs and FHWs
Profile of respondents
Of 189 respondents across surveys, 62% were SHLs (n=118) and 38% were FHWs (n=71) (table 2). Of scholars surveyed (N=286), there was a 26% (n=74) response rate.
Table 2. Profile of respondents.
| SHLs (N=118) |
FHWs (N=71) |
All (N=189) |
|
|---|---|---|---|
| n (%) | n (%) | n (%) | |
| Sector | |||
| Hospital care | 64 (54) | 46 (65) | 110 (58) |
| Community care | 54 (46) | 25 (35) | 79 (42) |
| Length of time employed in role | |||
| <1 year | 4 (3) | 10 (14) | 14 (7) |
| 1–5 years | 43 (36) | 27 (38) | 70 (37) |
| 6–10 years | 15 (13) | 12 (17) | 27 (14) |
| ≥11 years | 56 (48) | 22 (31) | 78 (41) |
| Job role | |||
| SHL | |||
| Director nursing and midwifery, or assistant or group director | 31 (26) | – | 31 (17) |
| Clinical director, or group or national lead | 14 (12) | – | 14 (7) |
| Quality and safety lead | 31 (26) | – | 31 (17) |
| Senior healthcare manager (business, operations, directorate managers) | 42 (36) | – | 42 (22) |
| FHW | |||
| Clinical nurse manager, advanced nurse practitioner, clinical nurse specialist | – | 26 (37) | 26 (14) |
| Medical consultants, non-consultant hospital doctor | – | 29 (41) | 29 (15) |
| Allied healthcare professional | – | 12 (17) | 11 (6) |
| Quality manager | – | 4 (5) | 4 (2) |
| Country of work | |||
| Ireland | 113 (96) | 56 (79) | 168 (89) |
| Middle East | 4 (4) | 10 (14) | 14 (7) |
| Other (Europe, North America, Asia, Africa) | 1 (1) | 5 (6) | 6 (3) |
| Data source | |||
| HSE survey | 99 (84) | 16 (22) | 115 (61) |
| RCSI scholars (MSc programmes) | 10 (9) | 31 (44) | 41 (22) |
| RCPI scholars (Certificate programme) | 9 (8) | 24 (34) | 33 (18) |
FHWs, frontline healthcare workers; HSE, Health Service Executive; MSc programmes, Master’s programmes; RCPI, Royal College of Physicians of Ireland; RCSI, Royal College of Surgeons in Ireland; SHLs, senior healthcare leaders.
Practical experience, training and self-rated knowledge of health economics methods
As displayed in table 3, approximately half of respondents had practical experience in the measurement of adverse events (55%), clinical (49%) and process (47%) outcomes.
Table 3. Practical experience in health economic methods and area of use.
| Practical experience (yes) | |||
|---|---|---|---|
| SHLs (N=118) |
FHWs (N=71) |
All (N=189) |
|
| Health economic methods: | n (%) | n (%) | n (%) |
| Measuring healthcare outcomes | |||
| (a) Clinical outcomes | 62 (53) | 30 (43) | 92 (49) |
| (b) Adverse events | 75 (64) | 28 (40) | 103 (55) |
| (c) Health-related quality of life | 23 (20) | 13 (19) | 36 (19) |
| (d) Quality-adjusted life years | 11 (9) | 3 (4) | 14 (7) |
| Measuring process outcomes (eg, length of stay, waiting times) | 63 (53) | 25 (36) | 88 (47) |
| Measuring healthcare costs | 48 (41) | 15 (21) | 63 (34) |
| Comparing costs and outcomes to identify value for money | 44 (37) | 10 (14) | 54 (29) |
| Analysing the budget impact of adopting initiatives to improve quality and safety | 36 (21) | 8 (11) | 44 (23) |
| Analysing the economic burden of disease | 7 (6) | 2 (3) | 9 (5) |
| Analysing health policies in terms of efficiency and equity | 23 (20) | 10 (14) | 33 (18) |
| None of the above | 4 (3) | 17 (24) | 21 (11) |
| Area of use of health economic methods: | |||
| Testing of an intervention in a clinical trial | 11 (8) | 8 (11) | 19 (10) |
| Measuring a quality improvement initiative | 66 (56) | 33 (46) | 99 (52) |
| Interpretation and implementation of a health policy | 24 (20) | 17 (24) | 41 (23) |
| Have training in health economic methods: | N=95 | N=58 | N=153 |
| Yes | 33 (35) | 6 (10) | 39 (25) |
FHWs, frontline healthcare workers; SHLs, senior healthcare leaders.
One-third or less had measured healthcare costs (34%), value for money (29%) or budget impact (23%). Less than 20% had analysed health policies in terms of efficiency and equity (18%), health-related quality of life (HRQoL) (19%), quality-adjusted life years (QALYs) (7%) and economic disease burden (5%). Overall, respondents’ application of these methods was in measurement of QI (52%), policy interpretation (22%) and clinical trial work (10%). A higher proportion of SHLs than FHWs had practical experience in the measurement of adverse events, healthcare costs, budget impact and value for money.
35% of SHLs and 10% of FHWs had received training in health economics. The most common forms were a health economics module as part of master’s (n=24)/degree (n=12) programmes and attendance at conferences (n=9) (online supplemental file 4).
Respondents’ self-rated knowledge in health economics methods reflected their practical experience (online supplemental file 4). A high proportion self-rated their knowledge as ‘good to excellent’ in measurement of adverse events (73%) and clinical outcomes (69%), and a low proportion rated knowledge of measurement of QALYs (20%) and economic burden of disease (22%) in this way.
Beliefs about the effect of health economic evidence on decision-making
Views about the influence of costs and outcomes data on decision-making in organisations varied without a clear pattern. 40% disagreed/strongly disagreed that information on cost and outcomes has ‘little influence on what quality and safety initiatives are resourced’, 28% neither agreed nor disagreed, 26% agreed/strongly agreed and 7% did not know. Additionally, 53% strongly agreed/agreed that ‘initiatives which demonstrate improved safety and decreased costs are most often widely implemented’, 31% neither agreed nor disagreed, 9% disagreed/strongly disagreed and 7% did not know (online supplemental file 5).
Enablers and barriers for using health economic evidence
59% of SHLs and 47% of FHWs felt their organisation expected them to use health economic evidence in managing quality and safety. A minority (SHLs, 27%; FHWs, 12%) reported organisational supports, such as working with financial colleagues, hospital boards and subcommittees. Most (SHLs, 62%; FHWs, 60%) identified organisational barriers, with 68 respondents describing 94 barriers, which formed 6 thematic barriers (online supplemental file 6). Respondents most frequently cited lack of education and training in health economics as a barrier (n=24; 35%):
Lack of awareness, skills and training. (SHL)
Limited if any opportunities to increase knowledge and skill. (FHW)
The lack of investment in health economics operational infrastructure (n=18; 26%), such as dedicated staffing, time and expertise, was another barrier. A frequent barrier (n=14; 21%), but reported by SHLs only, was poor availability and quality of cost and outcome data. Other barriers were disincentives (ie, a lack of expectation for, or impact of the evidence) (n=13; 19%) and lack of culture of using health economic analysis (n=13; 19%). Respondents commented that the term ‘health economic evidence’ is not commonly used and decisions are based on ‘competing priorities that have not had health economic assessment’. The silo management of cost and outcomes (n=12; 18%) due to information and computer technology (ICT) infrastructure, geography and managerial approach was also a barrier:
ICT infrastructure for clinical and financial info is absent particularly in the community. (SHL)
Limited flow of information and interaction between operational and clinical teams.(FHW)
Resources and competencies required to help support decision-making about quality and safety initiatives
Most respondents (72–91%) indicated resources would be ‘useful-very useful’ to support decision-making about quality and safety (table 4). The top three resources rated as ‘useful-very useful’ were implementation of value-based initiatives, access to the support and advice of health economists and a set of HEE competencies to guide learning and development. The vast majority (90–95%) felt the HEE competencies listed in the survey (table 4, items 6a–f) would be ‘useful-very useful’ in managing quality and safety.
Table 4. Respondent rating of the usefulness of health economic resources and competencies to support decision-making about quality and safety initiatives.
| Very useful | Useful | Limited use | Not useful at all | Do not know | |
|---|---|---|---|---|---|
| N=127 | n (%) | n (%) | n (%) | n (%) | n (%) |
| 1. Online learning on key principles of health economic evaluation | 49 (39) | 59 (47) | 16 (13) | 2 (2) | 1 (1) |
| 2. Access to collated library resources on health economic evaluation of quality and safety interventions | 30 (24) | 61 (48) | 28 (22) | 6 (5) | 2 (2) |
| 3. Access to the support and advice of health economists | 60 (47) | 53 (42) | 10 (8) | 2 (2) | 2 (2) |
| 4. Organisational policies on the requirement for economic evaluation of quality and safety interventions | 44 (35) | 58 (46) | 20 (16) | 3 (2) | 2 (2) |
| 5. Implementation of organisational initiatives to develop value-based healthcare in the organisation | 59 (47) | 56 (44) | 8 (6) | 1 (1) | 3 (2) |
| 6. A set of health economic evaluation competencies for HCPs to guide learning and development: | 49 (39) | 56 (44) | 19 (15) | 2 (2) | 1 (1) |
| (a) Understand the role of health economics in managing quality and safety | 63 (50) | 54 (43) | 7 (6) | 1 (1) | 1 (1) |
| (b) Understand the concept of opportunity cost (forgone opportunities) when selecting an improvement initiative | 53 (42) | 64 (51) | 8 (6) | 0 | 1 (1) |
| (c) Evaluate types of costs associated with quality improvement work when planning and monitoring an initiative | 55 (44) | 64 (51) | 7 (6) | 0 | 0 |
| (d) Apply cost outcome analysis to QI work to determine the cost and resource use associated with the initiative in comparison to the outcomes achieved | 54 (43) | 60 (48) | 10 (8) | 1 (1) | 1 (1) |
| (e) Apply cost-effectiveness techniques to resource allocation decisions when a new programme is both more effective and more expensive than a standard programme | 56 (44) | 58 (46) | 11 (9) | 0 | 1 (1) |
| (f) Analyse the budget impact of interventions after costs and outcomes have been established | 59 (47) | 61 (48) | 3 (2) | 1 (1) | 2 (2) |
HCPs, healthcare professionals; QI, quality improvement.
Refined health economic evaluation competencies
Following review of the findings from each of the datasets, our team developed core competencies for FHWs (‘understand the relationship between cost and quality in healthcare’ and ‘assess the basic costs and outcomes of a QI initiative’) and SHLs (‘understand and apply cost-effectiveness analysis to QI Initiatives’ and ‘advance capacity for improvement by applying cost-effectiveness analysis to decision-making’) (box 1). Each core competency had four to six subcompetencies. Building on our prior book chapter, increased emphasis was given to competencies for SHLs, in relation to measuring equity efficiency trade-offs and the budget impact of health economic decisions.
Box 1. Refined health economic competencies for frontline healthcare workers and senior healthcare leaders.
Frontline healthcare workers
Competency 1: Understand the relationship between cost and quality in healthcare
1.1 Recognise that quality improvement (QI) initiatives may impact on resource use and costs.
1.2 Recognise the concept of opportunity cost in selecting a QI initiative.
1.3 Understand there are trade-offs between efficiency and equity goals in designing QI initiatives across patient populations.
1.4 Understand the importance of measuring the impacts of QI initiatives on resource use, costs and outcomes.
1.5 Understand that QI benefits are often increased system capacity and not direct financial savings.
Competency 2: Assess the basic costs and outcomes of a QI initiative
2.1 Know the rationale for assessing cost and outcomes including the need to identify value-for-money and inform resource allocation decisions.
2.2 Understand the process for assessing the cost and outcomes of QI initiatives.
2.3 Be able to examine the costs and/or outcomes of a QI initiative using basic health economic techniques: ‘cost description’, ‘cost analysis’, ‘cost-outcome descriptions’.
2.4 Know how to articulate changes in targeted resource use, process and health outcomes and consequential savings and costs avoided.
Senior healthcare leaders
Competency 3: Understand and apply cost-effectiveness analysis to QI initiatives
3.1 Be able to identify and measure different types of costs associated with QI initiatives.
3.2 Understand the concept of cost-effectiveness analysis and its application in comparing QIs with similar outcome measures.
3.3 Be able to use cost-effectiveness analysis to analyse the costs of two or more similar initiatives, in comparison to their effects using a context-specific effect measure.
3.4 Be familiar with the cost-effectiveness plane and its use in interpreting economic analyses.
3.5 To establish value for money, be able to calculate the incremental cost-effectiveness ratio for initiatives identified as non-dominant (outcome and cost increasing).
3.6 Understand the concept of distributional cost-effectiveness analysis and its implications.
Competency 4: Advance capacity for healthcare improvement by applying cost-effectiveness analysis to decision-making
4.1 Routinely request cost evaluation as part of QI initiatives to incentivise decision-making incorporating cost and outcomes.
4.2 Be able to analyse the budget impact of QI programmes and health policies, once costs and outcomes have been established.
4.3 Be able to rank QI initiatives and health policies based on efficiency and equity goals, to inform strategic QI programming.
4.4 Be able to communicate the outcomes of economic evaluations and budget impact analyses to stakeholders and decision-makers, and related resource allocation decisions.
4.5 Know when to collaborate with health economists to conduct comprehensive economic evaluations, including assessments of health-related quality of life and quality-adjusted life years.
Discussion
There is demand for HEE competencies for those involved in quality and safety management in the Irish healthcare system, but few competencies are available from the literature. Nearly half of respondents believed use of health economic evidence in decision-making was an organisational expectation. Yet few had received training or measured costs, value-for-money and budget impact. Few had experience in health-economic metrics (HRQoL and QALYs) and efficiency and equity analysis. Respondents endorsed six HEE competencies for quality and safety management, indicating health economics should be an integral part of the education of healthcare professionals and managers. To enhance applicability and relevance, we have proposed four core competencies for our population group, tailored using the language of efficiency and equity, with increasing complex skills being required from SHLs.
Drawing on our research team’s prior published book chapter which offers a guide to HEE in QI1, refined competences were developed using tangible terminology about ‘costs’ and ‘outcomes’, since the term ‘health economics’ is rarely used in practice. To incentivise use of the competencies, we advocate that SHLs demonstrate sense-making and relating capabilities28 and share, in a transparent fashion, the reasons for resource-allocation decisions. This may address the barrier of not knowing if health economic evidence is influential of decisions and incentivise healthcare education providers to address the demand for health economic education for SHLs and FHWs engaged in QI. Given the HSE commissioned this work and incorporated a competency for measurement of cost and outcome in the new National Quality and Patient Safety Navigator, we believe now is an opportune time to address this educational gap. For example, we plan to include a link to this published paper in the Navigator, which is a live electronic document, incorporating educational and research resources. We are also applying the competencies ourselves with our student cohorts. For example, scholars are required to include health economic evaluation in QI project and dissertation work in both educational institutions who facilitated this research.
While influencing attitudes and skills with educational resources and guiding competencies is a feasible step, the research findings point to behavioural challenges which may take longer to address. For example, silo working was a barrier. Cross-boundary working among clinical and financial teams, and information systems is required. This, alongside data availability, would be particularly helpful for SHLs working across system, organisational and clinical levels. Yet, the Irish health system is poorly rated among European Union countries for digital health data accessibility.29 This may be a significant barrier to progress of the competencies, which require accessibility to cost and outcome data.
In terms of the educational resources required, guides to equity and cost analysis in QI have become available in recent years.1 30 Yet to our knowledge, there are few guides located within the QI literature that combine equity and efficiency analysis together. Such guides would be helpful for SHLs working at the systems levels and whose roles require balancing efficiency and equity concerns, primarily at the health organisation and systems levels. Several systematic reviews have been published on the feasibility of incorporating equity as part of decision-making criteria in cost-effectiveness analysis (CEA),17 and this work can be translated to QI contexts. For example, Cookson et al advocate the use of CEA for equity impact analysis (ie, distribution of cost and effects by socio-economic variables) and equity efficiency trade-off analysis (eg, improving total quality or equity objectives).17 For FHWs, who are unlikely to have budget responsibilities, building competence in equity-focused QI work and cost-analysis, as separate streams is likely to be sufficient in Ireland in the current operational environment.
Strengths and limitations
The study addressed an identified research gap and adds to debate. Contrary to other studies,31 32 it suggests that frontline healthcare professionals are interested in measurement of cost and outcomes even when this involves cost containment. Findings support recent research, among Irish medical practitioners and medical students alike, which has called for education in value-for-money principles such as high-value cost-conscious care.33 To support knowledge translation, our findings and proposed competencies were discussed on multiple occasions with the HSE National Quality and Safety Directorate, and the developers of the HSE Quality and Patient Safety Competency Navigator, a diverse co-design group. The skill of health economic evaluation is already empirically defined in the literature, and our addition is defining relevant competencies in language and at levels of competence, accessible to QI practitioners. Limitations were that the rapid literature review included English language papers only. The focus of competences was categorised according to cost-containment, efficiency and equity concepts. A potential limitation is that the categories of cost-containment and efficiency are not mutually exclusive. All efficiency efforts include a form of cost containment, for example, whereas equity efforts typically add costs. Therefore, our report of the efficiency/cost containment categories indicates an explicit or implied focus on cost containment, without clear demarcation between the two categories. Surveys were carried out predominantly in Ireland. The responses may have been different if multiple health systems were targeted. It was not possible to calculate a response rate for the SHL survey, due to the snowball sampling approach. Most of the FHWs who were surveyed were participants in educational programmes, and this may have biased them towards positive responses to the survey. At the same time, given their scholarly engagement, they were informed respondents and had an understanding of the competencies required to advance QI in Ireland.
Conclusion
Health economics is not an integral part of the training of healthcare workers—either at a clinical or managerial and leadership level. Our research has provided a framework of competencies that can be used for self-assessment and to develop or enhance educational and training programmes for healthcare staff at different levels of expertise. With increasing demand for healthcare and high-quality outcomes, the need for equitable use of limited resources is ever-present. We conclude it is logical and timely to add health economics to the day-to-day running of healthcare services and to the implementation and assessment of QI initiatives.
Supplementary material
Acknowledgements
The authors wish to thank the study respondents and gatekeepers who supported the research. Additionally, Mr Paul Murphy, RCSI Library Information Specialist, who assisted in the development of the rapid review search strategy.
Footnotes
Funding: HSE National Quality and Safety Directorate. No award grant number.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: The study was approved by the RCSI University of Medicine and Health Sciences Research Ethics Committee (REC212613751). Participants were sent electronic links to surveys via a gatekeeper. These enabled ticking of consent to participate at the start of the questionnaire surveys.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data relevant to the study are included in the article or uploaded as supplementary information.