An interview with: Keith Hurst and Kay Downey-Ennis
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Dr Keith Hurst is Senior Lecturer at the Institute of Health Sciences and Public Health Research, University of Leeds, where he researches into issues associated with health care management and quality assurance.
Kay Downey-Ennis is co-editor of the journal and is Director of Quality & Education at the Daughters of Charity of St Vincent de Paul (a service for those with learning disability) in Dublin.
The International Journal of Health Care Quality Assurance (IJHCQA) is concerned with the management of service quality in health care organizations worldwide. As such, it plugs a gap in the literature for an international and interdisciplinary journal and one that covers both the theoretical and the practical aspects of quality, management and continuous improvement of service in the field. In an industry beleaguered by administrative, staffing and financial difficulties, quality standards are notoriously difficult to achieve, so a journal which offers practical guidance grounded in research provides a much-needed resource, raising topical issues and providing an overview of current thinking.
The journal was originally founded by Professor Robin Gourlay, who has stepped down as editor. Keith Hurst was previously co-editor and recently took over as editor. The first issue of 2007 was dedicated to Professor Gourlay.
Editorial philosophy and general journal direction
How would you describe IJHCQA’s editorial philosophy, and what does quality assurance mean in this context?
Keith: When the journal was launched, quality was the main issue. Since then, management issues have become more important and if the journal was being commissioned now, it would have a name which reflected Shaw’s 3As and 3Es – broadening out from the concept of quality. This model covers our remit perfectly – the 3As are access, acceptability and appropriateness, while the 3Es are equity, effectiveness and efficiency. So we are now looking at more than patient satisfaction – it’s about efficiency and economy and value for money. The notion of quality is probably too narrow.
Shaw’s model also sums up the current situation as far as quality and health care is concerned. Certainly in the UK we are entering an era of variable financing – things are not going to grow as much as in recent years, making cost effectiveness very important. In the journal we are keen to put a spotlight on the issue of how do you maintain the quality of services in the light of diminishing resources, and when many of the services are in financial deficit, how do you retain high quality when practitioners are competing for resources? Then there is productive time – although I am not very comfortable with that term. What does productivity mean in the context of health care? Getting more patients through the system is not necessarily what it’s about.
The second main point is that despite decades of intensive research we still have a fairly weak evidence base about what does and doesn’t work in health care. So like other journals in the area, we are concerned to build a firmer evidence base for practitioners.
What is your primary and secondary audience?
Keith: I’d be hard pressed to make the distinction between primary and secondary audiences – 40 per cent of our authorship is medical practitioners, 15 per cent is nurses and allied health professionals, and 45 per cent is academics, which is quite a nice mix, although there may be a combination of roles for some of the authors. Nurses tend to go for the nursing QA journals, so although we get some nursing material it doesn’t really make a dent in the statistics.
Kay: The journal is aimed at advanced practitioners, who are doing pure research papers using advanced research methodology, as the primary audience, with the secondary one being fledgling practitioners, doing work based projects.
When I did my postgraduate studies, I found the journal very helpful, and when I mentioned this to Robin Gourlay, he was delighted. The particular market is health professionals and importantly, those who are concerned with quality management – with varied titles including Quality Managers, Performance Improvement Managers, Accreditation Coordinators etc.
It’s important to give such people the scope to write a paper, because it broadens their horizons and helps other people to learn. Quite small things make a difference in health care. For example, one of my students did an assignment on developing a standard for team based performance. I could see that it would be of great benefit to others but she was astonished when I suggested publication!
Do you think you are close to being an academic or a practitioner journal?
Keith: Many of the competing journals are closer to the academic end of the spectrum, and some of their material is quite dense. We make a phenomenal effort to ensure that our journal is readable and relevant to practice. We are slipping towards the academic end, but I don’t think we have crossed the boundary and we are still practice focused. What’s pushing us in the academic direction is the increase in quantitative material.
On a scale of 0-10, with 0 being academic and 10 being practitioner, I would say we were at 5/6. Are we moving closer to the academic end? There is a lot of more heavyweight material coming in, we’ve had some quite dense stuff, but I always urge authors to include practice recommendations, even if that makes their article exceed the stipulated length of 8,000 words. Practice relevance is always in the forefront of our minds, and we are never frightened of asking for more information as to how research can be applied.
The fact that we have papers that use high-level statistical techniques such as randomized, multi-centred trials, etc., means that word is out that we can do both practitioner and academic, qualitative and quantitative, and that we can peer review the heavyweight, strongly quantitative and more empirical papers. But we are still happy to entertain the more qualitative papers, which can be easier to read.
Kay: The perception is that quantitative research is very rigorous and scientific, whereas qualitative research may be open to more bias. We need the quantitative research to triangulate with the qualitative, and we also need practitioners to do this research. This can be daunting and it can be very challenging to get practitioners to write papers, and when they do write they need a lot of support. Equally it can be rewarding when you help them and you then see how satisfied they are.
Isn’t there a difficulty here in that practitioners may not have the time, inclination or training to do this kind of serious research?
Kay: It isn’t the norm to do research, mainly because of lack of time. Not all people in the field will have a Masters in Quality Management, and you don’t learn research skills unless you go through the academic process, although there are now a lot of standalone courses in research methods. People need to be constantly encouraged to write up their research.
In Ireland we have quality awards which help the research agenda – in order to qualify for an award you have to submit a research project. I’ve got my ear to the ground for these, and other developments, and I’m always on people’s backs urging them to publish, because it fits in with the remit of the journal. Many find it very daunting, and although time pressures get in the way of research, you need to make time.
It can be very important to work with the practitioners on the research as well as the language – sometimes you get a paper where you find the bare bones of an article, but it has to be worked on. In such cases, it can be down to the editor rather than the practitioner to bring it up to a point where we can publish.
How does this happen in practice? Through many, many e-mails! We work on the paper at the beginning on the grammar, but we also get reviewers (normally two) with expertise of that topic, and if possible research methodology. We go back to the authors with requests for changes. It may be that they need to consult more of the literature, or we may ask them to make the research more robust.
The advantage of the quality awards we have in Ireland is that you can contact the authors at an early stage, before they have written up the research. We might suggest that they do a bit of pure research to make the project more robust.
We also welcome approaches from practitioners who contact us about research in progress, and we can advise them whether or not it’s likely to be publishable.
How does IJHCQA differ from other journals in the field of healthcare management, particularly those published by Emerald, for example Clinical Governance: An International Journal, but also other non Emerald journals such as Journal of Nursing Quality Assurance or Quality Assurance in Health Care?
Keith: Our journal is truly multidisciplinary, and we’ve never concentrated on just one aspect of health care as do, say, some of the nursing journals. Also, because Kay and I are both at the coal face, we know what’s topical or about to become so, and we can grab it and work with it. Clinical Governance has a different focus and we work with its editors to avoid overlap. Also unlike CG, we also look at issues.
How important is the journal’s international remit?
Keith: The reason why we have a niche is that there are very few "quality" journals which are truly global – only a handful in fact. We both try to include those countries that are less represented on the international stage, and in the last few years we have published more material from Asia, particularly India and Pakistan. We are keen to put a spotlight on these and other countries, because we know that they have quite a bit to offer, but may find it difficult to get accepted by international journals.
The problem with this approach is that people are not writing in their first language, so while the topic is excellent and the research thorough, the English may require much work to bring the paper up to a publishable standard, and the authors may not grasp the subtleties of suggested changes. But we stand firm in our philosophy of giving exposure to less published countries, whilst some editors of international journals may just look at a few paragraphs and then reject.
Kay: I would agree with Keith that we are always trying to bring in different countries, continents and disciplines, and we are committed to doing extra work with people who have difficulties in English. Many EAB members are also committed to bringing in people from the less advanced world to publish their papers.
You state on your web pages that "Existing literature currently lacks a coherent and interdisciplinary focus for the particular quality concerns in this field". What is the value and necessity of having an interdisciplinary focus?
Keith: You see debates in the health care literature about specialist and generalist practitioner roles, and there have been attempts to look at ways of crossing health care boundaries (for example the practice nurse or nurse practitioner, who can prescribe), but the old multidisciplinary approach with nurses, therapists and pharmacists, etc. working together is coming back. This diversity of roles is reflected in our author teams, and most of the time we have four or five authors working together who reflect different professional backgrounds. They have taken a multidisciplinary approach and reported it accordingly; they are arriving at the same destination but going along a different route.
The multidisciplinary teams bring a more complete picture with all the dimensions covered, reflecting the three As and three Es, and such an approach brings its own checks and balances and creates more robust solutions – the whole is greater than the parts.
Kay: The interdisciplinary side is very important for patient care – nothing will happen in the health sector without a multidisciplinary input. However we don’t do it well and we lag behind many other sectors, for example the airline industry, where everybody very much works together as a team. In the health sector, there are still boundaries between disciplines, from all sides, not just nurses and doctors. Although that has changed slightly with undergraduate training for nurses which has given them greater confidence.
I note that you have a "News and Views" section which gives short snippets on particular quality initiatives. What is the thinking behind this?
Keith: The rationale when Robin started it was to have more than just book reviews, but also to have reviews of projects, so as to get a better overview of what’s happening on the ground. Jo [Lamb-White, Centre-section Editor] does a great job. We have material from all over the world, and sometimes I’ve drawn inspiration for my editorial.
How is the journal developing?
Keith: We are trying to improve our citation count; the agency (Thomson ISI) looks for the number of times our journal is cited in the related journals. We are also targeting more quantitative based articles, although there’s a little way to go before we achieve a balance between quantitative and qualitative. Finally, we are now electronic submission only, which speeds up the publication process. Andrea Watson-Lee, who manages Manuscript Central at Emerald, has been a great help. Between 2006 and 2008, we published four special issues: managed care; patient satisfaction; patient safety; and our 20th anniversary commemorative issue. We have been delighted with authors' response to our call for articles. We’ve invited one of our EAB members, Mosad Zineldin, to compile two more special issues following a successful conference he organized last year.
Your editorial role
Keith, you recently took over as editor from the man responsible for shaping and directing the journal, Professor Robin Gourlay. How does this feel, and how do you intend to take the journal forward?
Keith: I worked with Robin for 15 years, he was the external examiner on the master's programmes that I ran at Leeds University, and I peer reviewed quantitative material for him for the journal. I became co-editor about three years ago, but it was still a big step to sit in the editor’s chair, even though I had a lot of support from Robin and from Vicky Williams (publisher at that time). I also inherited a healthy wadge of manuscripts so there was a lot of material to start with.
Kay, what is your background and how did you come to be co-editor of the journal?
Kay: I was a nurse, and I went into QM in the early 90s, the first person in Ireland to specialize in the field. My current role as Director of Quality and Education within my organization involves the implementation of quality. I also teach at tertiary level: undergraduates and post-graduates at Dublin City University and the Royal College of Surgeons. Students benefit from practical accounts of what does and doesn’t work – a merger of theory and practice. That serves to strengthen quality management on the ground as a discipline.
How do you work together as co-editors of the journal?
Keith: Coincidentally, I am doing a lot of fieldwork in Ireland, so we have the opportunity to meet face to face, and we also have a full editorial team meetingfull editorial team meetings either face-to-face or via teleconference. But I would say that 90 per cent of our communication is by email or phone. Kay is a former EAB member and has her own network of QA specialists, so she’s not found it too difficult to attract her own material.
Kay: We meet occasionally but mostly its three-way e-mail between us as editors and the Publisher. Keith has the rigorous research, I have the practitioner background. Keith has dipped his toe into the world of practice as well, and I have a little bit of the academic. It’s a good mix.
Quality issues
How do you quality control the journal itself?
Keith: We have steadily built up a peer review team over the last few years. One of us will read the manuscripts and then if we consider the manuscript appropriate we send it off to peer review, giving the reviewer a month to respond. We are quite firm with the reviewer about the time, as this is a way of controlling the time from submission to publication, which can be very long drawn out.
I will read the paper for general issues of syntax, punctuation, etc. before I send it off for double blind review – so the paper will be read at least three times. I’ll quite frequently edit the peer review so that negative comments can appear constructive.
Kay: Keith and I know most people on the EAB, they are asked to be there for their clinical or management expertise, so the journal does get a good peer review.
The article "A volunteer companion-observer intervention reduces falls on an acute aged care ward" by Donoghue et al. won an Outstanding Paper Award. What was it about this paper that made it so special?
Keith: It’s quite an arduous task selecting outstanding papers – I read a total of 250,000 words! I used two sets of criteria – the Bandolier system, which has criteria from the health service, and is good at judging quantitative papers, and that of Emerald, which is broader.
The Donoghue et al. article was a clear winner on several counts – it was simple, elegant, it tackled a Cinderella service (elderly care), it used a controlled trial approach, it was empirically strong, and robustly executed. Altogether it was a well crafted article by a multidisciplinary team and the people had had the foresight to run an evaluation along side the programme, which showed that the programme had reduced inpatient falls by 50 per cent. Evaluation is very important because you need firm evidence.
Future plans
You plan to dedicate the first issue of this year to Professor Gourlay. What form will this issue take?
Keith: We are taking four articles from Issue 1 and will match them with articles on the same topic 20 years on, publishing side by side, so that we can see how the world the journal describes has moved on – an in some cases how it has stayed the same! Many of the new articles would not look out of place in Issue 1, although there is also much more quantitative material, which is the biggest difference. And, unbeknown to Robin, some of his friends have written tributes to him, including sadly one from Roger Dyson who died shortly after writing his piece.
What other plans do you have over the next 18 months?
Keith: : I’m revisiting the download statistics in order to examine which are the most popular topics, and check that they are covered. There will also other special issues on current hot topics. Kay, Nicola, Daisy and me (the editorial team) have been vicims of our own success. Our issues are full until the nd of 2010. For the first time in my life at Emerald we have a long waiting list of article ready or near readiness for publication. Unforttunately, that means we’re having to divert good material to other journals.
Kay: I would like to see more special issues on different topics for example something on clinical governance and quality would be very beneficial. That journal has a narrower focus and is very much concerned with fitness for practice. We need to correct the bias which sees quality assurance, health and safety and risk management as different disciplines: we are all clinicians working together.
I want to continue to have a focus on a bigger audience, and not to be too specific. I want us to stay with what Robin Gourlay started, which was a journal to help practitioners, both advanced and fledgling. It’s very important that we expand the evidence base for quality.
Publisher's note
Dr Keith Hurst and Kay Downey-Ennis were originally interviewed in September 2006. The interview was updated in Agust 2009.
Visit the information page for: International Journal of Health Care Quality Assurance