A 2013 study on the global burden of medical error found that unsafe care causes 43 million injuries a year and the loss of 23 million disability-adjusted life years (DALYs), about two-thirds of them in low- and middle-income countries (Jha et al., 2013). By these calculations, adverse events, if they were a disease, would be the fifth leading cause of DALYs lost worldwide (Jha et al., 2013). Sobering though they are, such figures are likely underestimates, as the study included problems resulting from only seven common adverse events in inpatient hospitalization, which people in poor countries access at far lower rates than in rich ones. Furthermore, the data that inform these estimates come largely from medical records systems, which are inadequate in most low- and middle-income countries. Although the true scope of unsafe hospital care remains difficult to measure, the burden is clearly highest in the parts of the world with the least means to correct it (Adhikari, 2013).
There is reason to suspect quality problems with outpatient services as well. Studies employing standardized patient actors in India (both urban Delhi and rural Madhya Pradesh) found that only 4 percent of patients receive a correct diagnosis; 67 percent receive no diagnosis at all. When the researchers calculated the probability that the patient received treatment
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1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Institute of Medicine, and they should not be construed as reflecting any group consensus.
that does no harm, they found it ranged from .25 among diarrhea patients to .61 for pre-eclampsia. To put it another way, 75 percent of Indian children presenting at a clinic with diarrhea will receive a treatment that hurts them (Das et al., 2012).
Deficits in the quality of clinical care are only a small piece of the problem. The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm took a view of quality that incorporated efficiency, timeliness, patient-centeredness, and equity as important dimensions of care (IOM, 2001). This view of quality requires attention to human resources, infrastructure, communication, medicines safety, and logistics. Problems in these areas are no less detrimental to patient safety, but are harder to measure and rarely captured in morbidity and mortality data. In low- and middle-income countries, concern with access to services sometimes overshadows interest in the standard of the services provided (Berendes et al., 2011; Das, 2011).
The momentum for universal health coverage has underscored the problem of poor quality care in low- and middle-income countries. Universal coverage aims to make essential health services “of sufficient quality to be effective” available at a cost that does not expose the user to risk of financial hardship (WHO, 2012). It is an important piece of the post-2015 development agenda,2 and many countries are making the free provision of a basic package of essential services a priority (IOM, 2014). As governments and donors spend more on health, they have greater concern that the services they pay for are safe and effective and, therefore, have more reason to invest in quality improvement.
Quality of care is a priority for the U.S. Agency for International Development (USAID). The agency’s missions abroad and their host country partners work in quality improvement, but a lack of evidence about the best ways to facilitate such improvements has constrained their informed selection of interventions. In the absence of guidelines on how to invest, mission staff navigate an opaque market of quality improvement strategies. Six different methods—accreditation; client-oriented, provider-efficient services (COPE®); improvement collaborative; Standards-Based Management and Recognition (SBM-R); supervision; and clinical in-service training—currently make up the majority of this investment for USAID missions (see Box 1-1). The agency’s Bureau for Global Health estimates that these six methods account for about 80 percent of the missions’ spending on quality of care. As their already substantial investment in quality grows, there is demand for more scientific evidence on how to reliably improve quality of care in poor countries.
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2 The post-2015 development agenda is the set of targets for international development that will replace the Millennium Development Goals.
BOX 1-1
Six Quality Improvement Strategies Commonly Used in USAID Missions
Accreditation
Accreditation is an external quality evaluation through which an accrediting organization formally recognizes that an institution meets certain standards. Accreditation is usually a voluntary process, though some countries require accreditation for market entry or eligibility for government payment. The accrediting organization uses consensus standards to evaluate institutions, but there is wide variability in the evaluation process. Some accreditations rely largely on self-assessment; others require several weeks of on-site inspections from a team of accreditors.
Clinical In-Service Training
Clinical in-service training is a broad category of quality improvement strategies, including all training for health professionals who have already completed their formal credentialing process. In-service training is meant to either reinforce important concepts and practices or to introduce new knowledge about how a health professional should work.
COPE® (client-oriented, provider-efficient services)
COPE® is EngenderHealth’s proprietary quality improvement method; it was designed for quality improvement in family planning and is now also used in maternal, child, and reproductive health. The strategy uses group problem solving and self-assessment to identify problems and set priorities for quality improvement. COPE® starts with an orientation for managers at the worksite, followed by a self-assessment where participants identify and rank their main problems. Facilitators help determine the root causes of these problems and develop action plans to fix them; the facilitator also helps select a COPE® committee, which is responsible for implementing and monitoring the action plan that staff develop. Three to 4 months after the first self-assessment, facilitators re-visit the implementing staff to review their progress and start the self-assessment process again. COPE® is meant to be implemented with other tools for continuous quality improvement, such as supervision and training.
Improvement Collaborative (also called collaborative improvement or, simply, collaboratives)
Improvement collaborative is a method for quality improvement developed in the 1990s at the Institute for Healthcare Improvement. Collaboratives aim to integrate into routine practice the best scientific evidence on how to improve outcomes and contain costs. To this end, they bring teams together with technical experts and process improvement coaches who use a continuous quality improvement process to make changes. The process uses iterative problem solving, encourages prompt
process improvements, and emphasizes ongoing measurement and monitoring. Collaboratives usually last about 9–24 months, during which time the participating teams analyze a problem and its causes; plan changes and test the results of these changes; work with the coaches to set performance targets and measure progress toward meeting them. Collaboratives can be used to improve processes for patients and providers, teams, organizations, or systems.
SBM-R (Standards-Based Management and Recognition)
SBM-R is a management method developed by Jhpiego that aims to improve quality of care by improving health worker performance. It adapts the four main elements of the continuous quality improvement cycle (plan, do, study, act) to standardize, do, study, and reward. In the first step, participants are made aware of the national standard and trained on that standard. Next, the participants put the standard into practice, taking an initial assessment and correcting areas where their practice falls short of the standard. The study step involves repeated measurement of progress, including provider self-assessments, internal assessment by facility staff and managers, and external assessments. In the final step, the health workers are recognized for their efforts; rewards, such as feedback, praise, and social recognition, are seen as important in maintaining motivation.
Supportive Supervision
Supportive supervision refers to a process of working with staff to set goals, identify and correct problems, and monitor staff performance. It generally takes one of three forms: managerial, clinical, or educational.
SOURCE: Workshop read-ahead memo.
USAID missions, and many other organizations spending on quality improvement, would welcome more information about how different strategies work to improve quality, when and where certain tools are most effective, and the best ways to measure success and shortcomings. Such evidence would allow funders to make better-informed decisions about quality improvement programming. A better understanding of the evidence supporting different quality improvement tools and clarity on the causal pathways through which they work would, in turn, help advance the global quality improvement agenda.
On January 28–29, 2015, the IOM convened a 2-day workshop on improving quality of care in low- and middle-income countries. (See Box 1-2
An ad hoc committee will plan a 2-day, public workshop on approaches to improving quality of care in low- and middle-income countries. A number of approaches to improving quality of health care are currently in use in low- and middle-income countries. These approaches are distinguished by distinct names, many of which are associated with specific organizations. The range of choices available has contributed to lack of clarity among U.S. Agency for International Development (USAID) missions and their counterparts. USAID requests that this workshop illuminate six different methods currently being used to improve quality of care in low- and middle-income countries, discussing their pros and cons. These methods are clinical in-service training; supervision; standards-based management and recognition; the client-oriented, provider-efficient method; improvement collaborative; and facility accreditation based on external evaluation. Evidence supporting these models might pertain to their cost-effectiveness, sustainability after donor support ends, and the degree to which these models have been made part of regular operations of the health system.
The public workshop will feature invited presentations and panel discussions. The planning committee will organize the workshop, select speakers and panelists, and serve as discussion moderators. Commissioned papers may be required to inform workshop discussions. A designated rapporteur or rapporteurs will prepare the workshop summary in accordance with institutional guidelines.
for the statement of task.) This workshop grew out of discussions between the IOM Standing Committee to Support USAID’s Engagement in Health Systems Strengthening in Response to the Economic Transition of Health (hereafter, the standing committee) and the agency’s Office of Health Systems. The workshop planning committee arranged the workshop agenda and invited a range of speakers from various organizations to respond to the statement of task.
This workshop summary is a description of the presentations and discussions as they occurred at the January workshop. The material is presented in roughly the order in which it was discussed, and the report is organized into sections corresponding to the sessions on the meeting agenda (see Appendix A). Views and opinions presented are those of individual speakers and do not reflect the consensus of the group, the planning committee, the IOM, or the workshop sponsor.
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