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LAC SOTA

LAC SOTA. Quality Improvement Session March 15, 2001 James Heiby, G/PHN/HN. Quality of Care. Start with focus on provider compliance with evidence-based clinical guidelines Process of care as pathway to impact Global trend: developed and developing countries

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LAC SOTA

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  1. LAC SOTA Quality Improvement Session March 15, 2001 James Heiby, G/PHN/HN

  2. Quality of Care • Start with focus on provider compliance with evidence-based clinical guidelines • Process of care as pathway to impact • Global trend: developed and developing countries • Prominent examples: IMCI, EOC, TB Case Management

  3. Implications of Clinical Guidelines • Well suited for basic services • But lack of management systems to support compliance • Large number of tasks at issue • Use reduces variation in care • Principles apply to administrative processes:When the same process is carried out repeatedly, invest in finding out the best way

  4. Clinical Guidelines as Tools • Mechanism to communicate current science • How developed affects feasibility and acceptance by providers: participation • Need to evaluate and modify • Clear, user-friendly presentation • First step: Make them available

  5. Standards for Neonatal Resuscitation will be Applied at Each Delivery

  6. Guidelines:Some Issues • What constitutes a good guideline? • How important is compliance ? • If it’s 30 or 40% • If levels of compliance are unknown • If there’s no standard in the first place • Relationship to decentralization, other health reforms • Future demands: MDRTB, AIDS, anti-microbial resistance, IPC

  7. Quality Assessment and Monitoring • Numerous external studies of quality • Emphasis on observers with instruments • Suggest widespread deficiencies • Few programs currently monitor compliance with guidelines • large numbers of health processes to monitor: need for new indicators • Measurement is essential for improvement strategies

  8. ARI Case Management in 17 WHO Facility Surveys (1995) • pneu= pneumonia cases correctly managed (%) • advis= caretakers correctly advised • antib= inappropriate use of antibiotics • range: 2-82%

  9. Issues for Quality Assessment and Monitoring • Every approach has strengths and weaknesses • Several promising approaches, but not well-studied • Strategies using a mix of methods • emphasize simplest methods, with validation through more rigorous ones • logical but poorly studied • Measures to support honest reporting

  10. Methodologies for Routine Monitoring of Quality • Observation with instrument • Supervisor checklists • External teams: accreditation model • Peer assessment • Self-assessment • Competency testing: clinical “vignettes”, interviews • Surrogate patient • Improved medical records/audit

  11. Quality Indicators in Ecuadorian Hospitals • % children <5 with ARI with 4 IMCI danger signs evaluated • % prenatal sessions that include all 14 standard services • % listed IMCI drugs in stock during the month

  12. Quality Indicators in Bangladesh PVO Program • Basic MCH/FP services: >800 tasks • 24 PVOs, 109 clinics • 46 indicators of quality in 5 main groups: • physical plant • provider technical competence • follow-up and referral • logistics • supervision/coordination

  13. Bangladesh PVO Program Quality Indicators • Each indicator scored as: • 0-not acceptable • .5-acceptable • 1-”star” • All indicators given equal weight • Indicators averaged for reporting by main groups: “quality coefficient”

  14. Quality Coefficients in Bangladesh PVO Program

  15. Strategies for Promoting Compliance with Guidelines • Established approaches: • Technical training • skills and knowledge necessary • guidelines define competencies • improving the cost-effectiveness of training • limitations of training: “Performance Improvement” • Supportive supervision, technical assistance • well-defined strategies ? • cost and effectiveness

  16. Observed IMCI Skill Score byTraining Type over Time Main Finding: No difference in IMCI skills between the two training types at each period of observation.

  17. Strategies for Promoting Compliance with Guidelines • Approaches from the QA field • sustained communication of guidelines • large developed country literature • underlying rationale • endorsement by authorities • clinical case studies • self-assessment • performance feedback • objective feedback to providers is uncommon • limited research suggests potential

  18. Quality of Interpersonal Communication in Indonesia • Study design: • Control: training only • Training plus self assessment • Training, self assessment, plus peer review • Assessments at baseline, 1, and 4 months

  19. Strategies for Promoting Compliance with Guidelines • Systematic design of job aids • IMCI recording form • Critical pathways for EOC • Client memory aid for antibiotics • Instructions for malaria diagnostic test • Managed incentive systems • material • non-material • Personnel systems

  20. Quality Improvement/Problem Solving • Industrial model: quality management, TQM, CQI • Widely used in US, other DCs • Expanding use in LDCs; hundreds of local applications • Provides a framework for problem solving • Intangible benefit: change in attitude toward problems, “culture of quality”

  21. Problem: high rate of malaria “re-attendants” Team’s analysis 23% of malaria patients returned 84% forgot instructions Evidence of discarded drugs Interventions directly observed dose of SP educate community on treatment instructions Blood smear for all re-attendants Salima: Improving Patient Compliance-Malaria

  22. Re-attendant Malaria Patients in Salima Clinic, Malawi

  23. Blantyre, Malawi: Preparing for IMCI Implementation • Problem identified: provider time with patients too brief for IMCI, waiting times already long • Data collection: client flow, staff time Interventions tested: • reorganized registration system • changed staffing pattern • introduced one-way flow for patients • lunch hour changes

  24. Results: Increased Contact Time and Decreased Waiting

  25. Study 2: Problem-Solving Teams Intervention • Supervisors from 2 districts trained and coached 23 facility-based teams • Teams problem-solve using simple quality tools • Teams assigned the problem of improving IMCI performance, but selected own solutions to implement

  26. Solutions Implemented by Teams Number of teams

  27. Improvement Trends in IMCI Case Management,* 1998-2000 Percentage point improvement *Based on composite index of 4 aspects: assessment, classification, treatment, counseling **n=number of facilities

  28. Quality Improvement/Problem Solving • Remaining issues: • weak documentation by most teams • potential for wider use of local team experiences • need for increased focus on clinical care • cost-effectiveness comparison of CQI with streamlined methodologies • incentives for teams • longitudinal evaluations

  29. The Design of Health Services • How the work of staff, performing different sets of tasks is organized • The design of a “system of care” for a given condition can include community through referral hospital • Re-design: if current design doesn’t make sense • Relationship to QI: fixing specific problems vs. starting over

  30. The Design of Health Services • Methodology: a stepwise process for incorporating the views of stakeholders within resource constraints • LAMM initiative: EOC • May be useful when introducing new clinical standards, like IMCI • Tver, Russia: re-design of system of care of neonates to implement new EBGs:

  31. Key Results of (Re)Designing the System of Neonatal Care in Tver • 93% 7-day survival rate after initial resuscitation • 46% increase in neonates transported to NICU with normal body temperature • 63% reduction in neonatal mortality due to RDS

  32. Regulatory Strategies • Major examples: • Accreditation of facilities and training programs • Certification of specialized competencies • Licensing of professionals and hospitals • Based on transparent, external evaluation of care or competence • Usually periodic, time -limited • Assessment has consequences

  33. Regulatory Strategies • Accreditation and certification not limited to government bodies • Provides consumers with a “report card” • Limited alternatives for influencing quality in the private sector • LDC programs expanding • Recent innovations in DCs: • re-testing for licensing • assistance to improve vs. punitive action

  34. Whether Mystery Shoppers Were Sold Correct Drugs (Shoppers=203) (Shoppers=302) *Correct type was defined as an effective SP plus an antipyretic. Significant difference at p<.000.

  35. Issues for Discussion • Organization of QA activities that are accountable for resources used and results • Evaluation of QA programs • Relationship of cost and quality • Potential contribution of human resources approaches • Role of the community in QA

  36. Issues for Discussion • QA and health reform issues such as decentralization and financing • Applications to HIV/AIDS, TB, and anti-microbial resistance • QA in pre-service training • Role of international lenders • Patient satisfaction and utilization

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