Improving Quality of Care in Low- and Middle-Income Countries Workshop Summary (2015) / Chapter Skim
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3 Six Widely Used Methods to Improve Quality
3 Six Widely Used Methods to Improve Quality
Pages 13-34
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From page 13... ...
Quality improvement tools are more concerned with changing one area of a system, less with routine mea suring against normative standards. The six methods discussed at the workshop fall across the continuum from quality assurance to quality improvement.
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From page 14... ...
Although randomized trials are still the gold standard evaluation technique, they are a bit reductionist in relation to complex quality improvement programs. Even if cluster randomized trials of the different interventions show success, it is not always possible to say which process or tool drove the success, or to isolate effect sizes for different pieces of the intervention.
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From page 15... ...
Barker placed these terms in the health context, explaining that quality planning refers to policy decisions affecting the way resources are coordinated and the checks in place to ensure accountability, while quality control refers to national guidelines and systems for professional oversight and accreditation and uses tools such as checklists and standards. Figure 3-1 shows how all three pieces of the Juran trilogy drive changes in the way systems perform.
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From page 16... ...
Aspire to a best performance goal goal across multiple parts of the system for a focused improvement area Measurement Periodic inspection of past events Continuous tracking of current (large set of measures of inputs activity (few key processes linked and/or processes) to outcome)
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. After a quality improvement program, the percentage COPEof eligible women receiving the corticosteroid increased rapidly and stayed that way, with a few lapses during manage SBM-R FIGURE 3-2 Putting the six methods on a continuum from quality assurance (QA)
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From page 18... ...
The program's success could not be sustained because it depended on larger systemic factors, including the commitment of management up to the national level and the procurement of essential medicines. In this example, the hospital is something of a micro-health system, but sustaining success depends on factors beyond the hospital itself, such as the district policies, management's commitment, and a reliable medicines supply.
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From page 19... ...
The COPE® package has four main pieces: a handbook; a self-assessment guide that requires a systematic analysis of how services are provided; client interview guides that set out how staff members should talk to clients and identify what clients consider to be good quality care; and a client flow analysis to monitor how long clients are waiting and how long their contact with providers lasts. Figure 3-4 shows how the process and tools used in COPE® support continuous assessment of health services.
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From page 20... ...
2005. Improving the quality of child health services: Participatory action by providers.
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From page 21... ...
© Reproduced by permission of EngenderHealth. presentation by observing that COPE®, like all quality interventions, is not the only way to effect change and that the method works best when it is a piece of a larger quality strategy.
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From page 22... ...
Clear written standards are key to SBM-R; these standards are developed with the host country counterparts and take considerable input from local stakeholder groups. Necochea shared an example of a standard (see Figure 3-8)
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From page 23... ...
His remarks were not limited to the accreditation process of his organization, Joint Commission International, but he did draw some examples from their work. VanOstenberg defined accreditation as "a voluntary process by which a 1 LiST, or the Lives Saved Tool, uses national demographic projections, burden of disease, and information about program effectiveness to estimate the effects of changes in the coverage of different maternal and child health interventions.
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From page 24... ...
Reproduced by permission of Jhpiego Corporation. FIGURE 3-10 Results from a comparative study showing the trends in maternal health service delivery practices and health outcomes after SBM-R was implemented in 102 facilities in Mozambique, 2009–2013.
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From page 25... ...
Each institution chooses its own path to meet the accreditation standard; in that way, the process is a vehicle for different quality improvement methods. Because accreditation requires regular re-review, it encourages a culture of continuous quality improvement.
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From page 26... ...
VanOstenberg mentioned the dearth of literature from the rest of the world and cautioned that accreditation is a tool for continuous quality improvement, not a substitute for a national licensure system that codifies the national minimum standards for health. Discussion In the discussion following their presentations, the panelists gave their views on what makes a quality program sustainable.
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From page 27... ...
Collaborative improvement can address clinical or managerial topics, such as recordkeeping and waiting times. As URC implements them, the collaboratives work on problems the host country and the USAID mission have identified as priorities.
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From page 28... ...
Solutions identified through collaboratives are already suited to the local context; the process of identifying and implementing these solutions builds local capacity and empowers managers to pursue con
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From page 29... ...
with all four medications % of acute coronary syndrome patients with initial treatment 44% <0.001 (morphine, oxygen, nitrate, aspirin) recorded % of COPD patients where all risk factors recorded (smoking, 91% <0.001 body mass index, physical activity)
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From page 30... ...
English explained that, in an attempt to minimize the costs of training, global health programs often use a cascading model for in-service training in which the student who attends a training is responsible for educating a larger group at his or her home office. Educational theory offers little evidence to support this model.
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From page 31... ...
In the 2008 and 2011 reviews, Bosch-Capblanch and his colleagues found that quality changes are more meaningful and sustainable when super ision is part of a bigger program that includes health worker training, v incentives, and improved supply chain management. The 2011 Cochrane review found nine studies of suitable rigor for in
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From page 32... ...
The literature is not always clear about separating the supervision intervention from the incentives that go along with it, such as bonus pay or supply chain reform. Bosch-Capblanch echoed English's sentiment that it is difficult to articulate the causal pathway by which supervision changes health outcomes, a problem his team has been struggling with as they update the Cochrane review on supervision and quality of care.
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From page 33... ...
SIX WIDELY USED METHODS TO IMPROVE QUALITY 33 lack of a clear analytic framework prevents any meaningful understanding of supervision or its effects. Bosch-Capblanch cited the development of such a framework as his group's top priority; otherwise there is the risk of doing pointless research on outcomes that turn out to be irrelevant to the intervention.
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