Quality of Care in Developing Countries

1. Quality of Care in Developing Countries Dr Chilunga Puta Disease Control Priorities in East Africa Kilimanjaro Kempinsky Hotel, Dar es Salaam 21-23 August, 2007 Regional Centre for Quality of Health Care, Uganda

2. Objectives of Presentation • This presentation will elaborate: • The definition of quality • A framework for quality of care • Policy interventions to improve quality • Measurement of quality • Economic benefits and costs of quality Regional Centre for Quality of Health Care, Uganda

3. CONCEPTS IN QUALITY OF CARE Regional Centre for Quality of Health Care, Uganda

4. Defining Quality Health CareGroup Exercise • What is quality health care? • Take a few minutes to reflect on the meaning of quality • write your own definition on a VIPP card • Stick the card on the wall • What picture emerges from the various definitions? Regional Centre for Quality of Health Care, Uganda

5. A Definition of Quality… • ‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (Institute of Medicine, 2001) Institute of Medicine, 2001: Crossing the Quality Chasm, Washington, DC: National Academy Press Regional Centre for Quality of Health Care, Uganda

6. Elements of Quality -1 • Quality comprises three elements: • Structure • Stable material characteristics (infrastructure, tools, technology) • Resources of the organization • Financing of care Regional Centre for Quality of Health Care, Uganda

7. Elements of Quality-2 • Quality comprises three elements: • Process • transformation of inputs from the health care system into health outcomes Regional Centre for Quality of Health Care, Uganda

8. Elements of Quality-3 • Quality comprises three elements: • Outcomes • health status • Deaths • morbidity • Disability adjusted years • Patient satisfaction or responsiveness to the health care system Regional Centre for Quality of Health Care, Uganda

9. Elements of Quality - 4 • Structure • In most developing countries: • Shortages of medical staff • Shortages of medical supplies such as medication • Inadequate facilities and poor infrastructure Regional Centre for Quality of Health Care, Uganda

10. Elements of Quality - 5 • Structure cont. • Evidence suggests weak link between structural elements and health outcome except where physical improvements: • Increase access or • Increase volume of a clinical procedure Regional Centre for Quality of Health Care, Uganda

11. Elements of Quality - 6 • Process (interaction between caregiver and patients) • Can be measured with every visit but sometimes difficult to measure because: • Consultations are private • Lack of measurement criteria • reliable measurement tools may not be available Regional Centre for Quality of Health Care, Uganda

12. Elements of Quality - 7 • Process cont. • New methods being developed to provide valid measures of clinical practice • Evidence is emerging for which process measures lead to better health outcomes Regional Centre for Quality of Health Care, Uganda

13. Elements of Quality - 8 • Process cont. • Combination of ubiquity, measurability and linkage to health outcomes makes measurement of process the preferred way to assess quality Regional Centre for Quality of Health Care, Uganda

14. Elements of Quality - 9 • Contextual elements illuminating how process changes can improve care include: • Patient safety • Effectiveness • Patient centeredness • Timeliness • Efficiency • Equity Regional Centre for Quality of Health Care, Uganda

15. Elements of Quality - 10 • Outcomes • Not an efficient way to measure quality • Patients can still recover even if they get poor quality care • Patients can fail to recover even if they get good quality of care • Adverse health outcomes do not occur with every encounter Regional Centre for Quality of Health Care, Uganda

16. Perspectives of Quality • Quality can be assessed from different view points: • Health care provider perspective (technical/professional) • Patient perspective • Community perspective • Health financier perspective • Administrative perspective etc. Regional Centre for Quality of Health Care, Uganda

17. Patient Perspective 1 • Determined by: • Individual characteristics that affect • Compliance • Follow –up decisions • Long-term lifestyle changes Regional Centre for Quality of Health Care, Uganda

18. Patient Perspective 2 • Patient access and utilization affected by • Interpersonal relationships • Cultural appropriateness • Gender sensitivity • Patient satisfaction and patient responsiveness are therefore important outcome measures Regional Centre for Quality of Health Care, Uganda

19. Technical/Professional Perspective • Strives to meet normative standards • Adherence to evidence-based criteria • Have evidence based quality criteria linked to better health outcomes Regional Centre for Quality of Health Care, Uganda

20. Quality of Care Framework Political Factors Institutional factors Health Policy Reforms Health care access Structure Process Health outcome Demographic/socioeconomic factors The Quality of Care Social Factors Cultural Factors Regional Centre for Quality of Health Care, Uganda Ref: Peabody et al 1999

21. QUALITY OF CARE IN DEVELOPING COUNTRIES Regional Centre for Quality of Health Care, Uganda

22. What Causes Poor Quality of Care? • Economic constraints (evidence suggests this contributes about 37 %) • Poor process (as much as 60%) • Other causes • Conclusion: it is beneficial to focus on processes Regional Centre for Quality of Health Care, Uganda

23. Evidence for Poor Processes • Nolan et al 2001: seven country study: • 75% cases not adequately diagnosed, treated, or monitored • DCP study of five developing countries: • Within country range of quality of doctors 10x as great as between country range Regional Centre for Quality of Health Care, Uganda

24. Evidence for Poor Processes • RCQHC review of health worker performance: • Uganda (2 districts, 6 diagnostic centers for TB) • 29% of the staff partly knew the treatment categories; 18% not sure; 53% did not know Regional Centre for Quality of Health Care, Uganda

25. Evidence for Poor Processes • 6% of staff knew all the treatment regimens recommended by NTLP; 29% knew the regimens for cases on re-treatment only; and 65% of the staffs were not sure • 24% of the staff adequately knew the case description of a TB suspect; 47% were not specific and 29% did not know Regional Centre for Quality of Health Care, Uganda

26. Policy Interventions for Quality of Care • Quality improvement policy: one that has ability to raise level of health and reduce variations in quality Regional Centre for Quality of Health Care, Uganda

27. Policy Interventions for Quality of Care • Two types of policy: • Those that influence provider behaviour by addressing • Structural conditions • Finance • Design or re-design of health systems • Those that directly target provider behaviour individually or collectively Regional Centre for Quality of Health Care, Uganda

28. Policy: Changing Structural Conditions • Two components of structure influences process: • Organization • Finance Regional Centre for Quality of Health Care, Uganda

29. Policy: Changing Structural Conditions • These influence process by changing the health care system: • Socioeconomic, • Legal, • Administrative, • Cultural, and • Information context Regional Centre for Quality of Health Care, Uganda

30. Policy: Changing Structural Conditions • Policy focus area: Legal mandates, accreditation and administrative regulations • Control entrance into practice of health care • Determines what functions health workers can legally perform Regional Centre for Quality of Health Care, Uganda

31. Policy: Changing Structural Conditions • Policy focus area: Legal mandates, accreditation and administrative regulations • Periodic hospital accreditation has potential to provide pressure for improvement • No evidence that these policies actually improve performance and health outcomes Regional Centre for Quality of Health Care, Uganda

32. Policy: Changing Structural Conditions • Policy focus area: Malpractice litigation to enforce legal mandate • To promote quality there must be adequate legal and judicial systems Regional Centre for Quality of Health Care, Uganda

33. Policy: Changing Structural Conditions • Policy focus area: Professional oversight • Peer review • Requires adequate data to inform improvement processes • Evidence for improved performance where workers are reviewed Regional Centre for Quality of Health Care, Uganda

34. Policy: Changing Structural Conditions • Policy focus area: Professional oversight • Can become “quality by inspection” leading to • Antagonistic relationships between workers and managers • Preclusion of cooperate problem solving Regional Centre for Quality of Health Care, Uganda

35. Policy: Changing Structural Conditions • Policy focus area: National and local clinical guidelines • Should be evidence based • Resource constraint may necessitate modification of guidelines • Include physicians in development and review of guidelines Regional Centre for Quality of Health Care, Uganda

36. Policy: Changing Structural Conditions • Policy focus area: Sharing Information on Quality Improvement Technology • Potential to accelerate the scale up of quality practice • Can help develop a system of effective research to improve quality of care • Promotes development of tools and articles for quality improvement Regional Centre for Quality of Health Care, Uganda

37. Policy: Changing Structural Conditions • Policy focus area: Public Private Provision of Care • Private sector provide significant amounts of care in developing countries • Public regulatory framework can lead to private provision of higher quality care e.g. Senegal (preventive nutrition services) Regional Centre for Quality of Health Care, Uganda

38. Policy: Changing Structural Conditions • Policy focus area: Targeted Education and Professional Re-training • Targeted learning, case-based learning, interactive teaching techniques have had success in improving health outcomes e.g. TZ reduction in under five mortality within 2 years by training in control of acute respiratory infections Regional Centre for Quality of Health Care, Uganda

39. Policy: Changing Structural Conditions • Policy focus area: Organizational Change • Develop organizational and individual capabilities where they have greatest impact on the process of care • Better care is the product of many processes working together so isolated improvements will not succeed Regional Centre for Quality of Health Care, Uganda

40. Policy: Changing Structural Conditions • Policy focus area: Organizational Change • Models of organizational change: • Total Quality Management • Collaborative improvement model • Plan-Do-Study-Act-cycle (PDSA) • Internal enabling environment Regional Centre for Quality of Health Care, Uganda

41. Policy: Changing Structural Conditions • Total Quality Management (Continuous improvement) • Cycle of planning, implementing, evaluating and revising to improve Regional Centre for Quality of Health Care, Uganda

42. Policy: Changing Structural Conditions • Techniques include process mapping, statistical control and structured team activities • Example: Malawi NTP has successfully applied TQM to TB control processes Regional Centre for Quality of Health Care, Uganda

43. Policy: Changing Structural Conditions • Collaborative improvement cycle • Facilitates scale up of quality improvement initiatives • Aims at continuous organizational and individual performance Regional Centre for Quality of Health Care, Uganda

44. Policy: Changing Structural Conditions • Collaborative improvement cycle • Has 4 elements: • Definition of aim • Measurement Regional Centre for Quality of Health Care, Uganda

45. Policy: Changing Structural Conditions • Innovation • Testing whether innovation meets original aim • Currently being used in Uganda for HIV/AIDS program improvement Regional Centre for Quality of Health Care, Uganda

46. Policy: Changing Structural Conditions • Plan-Do-Act cycle (PDSA) • Action –oriented learning • Teams go through the cycle together to identify appropriate improvement methods • Useful for design and redesign of systems Regional Centre for Quality of Health Care, Uganda

47. Policy: Changing Structural Conditions • Internal Enabling Environment • Creation of enabling environment calls for: • Leadership and leadership training for QI • Resources for QI • Can be made by teams of individuals or a strong leader with interest in teamwork/QI Regional Centre for Quality of Health Care, Uganda

48. Policy: Directly Affecting Provider practice • Performance based feedback • Addresses solitary nature of clinical practice • Rewards high quality care • Increases knowledge about appropriate action • Can form basis for system wide incentives for improving quality of care Regional Centre for Quality of Health Care, Uganda

49. Policy: Directly Affecting Provider practice • Training with Peer Review feedback • Re-training in specific areas of medical practice, with peer review feedback ahs been shown to improve practice in Mexico city • Uses interactive training workshops and a managerial peer review committee Regional Centre for Quality of Health Care, Uganda

50. Policy: Directly Affecting Provider practice • Performance-Based Remuneration • Direct payments to providers meeting quality standards (based on process indicators associated with favorable patient outcomes) –used in USA: 3-10 % of provider’s compensation • Potential for accelerating quality improvement Regional Centre for Quality of Health Care, Uganda