LAC SOTALAC SOTA

Quality Improvement SessionQuality Improvement Session

March 15, 2001March 15, 2001

James Heiby, G/PHN/HNJames Heiby, G/PHN/HN

Quality of CareQuality of Care

Start with focus on provider Start with focus on provider compliance with evidence-based compliance with evidence-based clinical guidelinesclinical guidelines

Process of care as pathway to impactProcess of care as pathway to impact Global trend: developed and Global trend: developed and

developing countriesdeveloping countries Prominent examples: IMCI, EOC, TB Prominent examples: IMCI, EOC, TB

Case ManagementCase Management

Implications of Clinical Implications of Clinical GuidelinesGuidelines

Well suited for basic servicesWell suited for basic services But lack of management systems to But lack of management systems to

support compliancesupport compliance Large number of tasks at issueLarge number of tasks at issue Use reduces variation in careUse reduces variation in care Principles apply to administrative Principles apply to administrative

processes:When the same process is processes:When the same process is carried out repeatedly, invest in finding carried out repeatedly, invest in finding out the best wayout the best way

Clinical Guidelines as Clinical Guidelines as ToolsTools

Mechanism to communicate current Mechanism to communicate current sciencescience

How developed affects feasibility How developed affects feasibility and acceptance by providers: and acceptance by providers: participationparticipation

Need to evaluate and modifyNeed to evaluate and modify Clear, user-friendly presentationClear, user-friendly presentation First step: Make them availableFirst step: Make them available

Standards for Neonatal Resuscitation will be Applied at Each Delivery

Percentage of deliveries in which neonatal resuscitation guidelines were applied correctly

0

20

40

60

80

100

120

%

Guidelines:Some IssuesGuidelines:Some Issues

What constitutes a good guideline?What constitutes a good guideline? How important is compliance ?How important is compliance ?

– If it’s 30 or 40%If it’s 30 or 40%– If levels of compliance are unknown If levels of compliance are unknown – If there’s no standard in the first placeIf there’s no standard in the first place

Relationship to decentralization, other Relationship to decentralization, other health reformshealth reforms

Future demands: MDRTB, AIDS, anti-Future demands: MDRTB, AIDS, anti-microbial resistance, IPCmicrobial resistance, IPC

Quality Assessment and Quality Assessment and MonitoringMonitoring

Numerous external studies of qualityNumerous external studies of quality– Emphasis on observers with instrumentsEmphasis on observers with instruments– Suggest widespread deficienciesSuggest widespread deficiencies

Few programs currently monitor Few programs currently monitor compliance with guidelinescompliance with guidelines– large numbers of health processes to large numbers of health processes to

monitor: need for new indicatorsmonitor: need for new indicators Measurement is essential for Measurement is essential for

improvement strategiesimprovement strategies

ARI Case Management in ARI Case Management in 17 WHO Facility Surveys 17 WHO Facility Surveys

(1995)(1995)

pneu= pneumonia pneu= pneumonia cases correctly cases correctly managed (%)managed (%)

advis= caretakers advis= caretakers correctly advisedcorrectly advised

antib= antib= inappropriate use inappropriate use of antibiotics of antibiotics

range: 2-82%range: 2-82%

05

1015202530354045

pneu

advis

anti

b

median%

Issues for Quality Issues for Quality Assessment and Assessment and

MonitoringMonitoring

Every approach has strengths and Every approach has strengths and weaknessesweaknesses

Several promising approaches, but not Several promising approaches, but not well-studiedwell-studied

Strategies using a mix of methodsStrategies using a mix of methods– emphasize simplest methods, with emphasize simplest methods, with

validation through more rigorous onesvalidation through more rigorous ones– logical but poorly studiedlogical but poorly studied

Measures to support honest reportingMeasures to support honest reporting

Methodologies for Routine Methodologies for Routine Monitoring of QualityMonitoring of Quality

Observation with instrumentObservation with instrument– Supervisor checklistsSupervisor checklists– External teams: accreditation modelExternal teams: accreditation model– Peer assessmentPeer assessment– Self-assessmentSelf-assessment

Competency testing: clinical “vignettes”, Competency testing: clinical “vignettes”, interviewsinterviews

Surrogate patientSurrogate patient Improved medical records/auditImproved medical records/audit

Quality Indicators in Quality Indicators in Ecuadorian Hospitals Ecuadorian Hospitals

% children <5 with % children <5 with ARI with 4 IMCI ARI with 4 IMCI danger signs danger signs evaluatedevaluated

% prenatal sessions % prenatal sessions that include all 14 that include all 14 standard servicesstandard services

% listed IMCI drugs % listed IMCI drugs in stock during the in stock during the month month

0

10

20

30

40

50

60

70

80

June

Aug

ust

Oct

ARIprenataldrugs

Quality Indicators in Quality Indicators in Bangladesh PVO ProgramBangladesh PVO Program

Basic MCH/FP services: >800 tasksBasic MCH/FP services: >800 tasks 24 PVOs, 109 clinics24 PVOs, 109 clinics 46 indicators of quality in 5 main 46 indicators of quality in 5 main

groups:groups:– physical plantphysical plant– provider technical competenceprovider technical competence– follow-up and referralfollow-up and referral– logisticslogistics– supervision/coordination supervision/coordination

Bangladesh PVO Program Bangladesh PVO Program Quality IndicatorsQuality Indicators

Each indicator scored as:Each indicator scored as:– 0-not acceptable0-not acceptable– .5-acceptable.5-acceptable– 1-”star”1-”star”

All indicators given equal weightAll indicators given equal weight Indicators averaged for reporting by Indicators averaged for reporting by

main groups: “quality coefficient”main groups: “quality coefficient”

Quality Coefficients in Quality Coefficients in Bangladesh PVO ProgramBangladesh PVO Program

Variable Kanchan PVO Mamata PVOOverall .56 .64Tech comp-paramedic

.52 .59

Tech comp-physician

.54 .79

Tech comp-counselor

.25 1.00

Referral .33 .29supervision .33 .46

Strategies for Promoting Strategies for Promoting Compliance with Compliance with

GuidelinesGuidelines

Established approaches:Established approaches:– Technical trainingTechnical training

skills and knowledge necessary skills and knowledge necessary guidelines define competenciesguidelines define competencies improving the cost-effectiveness of trainingimproving the cost-effectiveness of training limitations of training: “Performance limitations of training: “Performance

Improvement”Improvement”

– Supportive supervision, technical assistanceSupportive supervision, technical assistance well-defined strategies ?well-defined strategies ? cost and effectivenesscost and effectiveness

Observed IMCI Skill Score byTraining Type over Time

88 89 86 84 82 84

0

20

40

60

80

100

End of Trg After 2 wks After 3 mos

Standard Computer Main Finding:No difference in IMCI skills between the two training types at each period of observation.

Strategies for Promoting Strategies for Promoting Compliance with Compliance with

GuidelinesGuidelines

Approaches from the QA field Approaches from the QA field – sustained communication of guidelinessustained communication of guidelines

large developed country literaturelarge developed country literature underlying rationaleunderlying rationale endorsement by authoritiesendorsement by authorities clinical case studiesclinical case studies

– self-assessment self-assessment – performance feedbackperformance feedback

objective feedback to providers is uncommonobjective feedback to providers is uncommon limited research suggests potentiallimited research suggests potential

Quality of Interpersonal Quality of Interpersonal Communication in Communication in

IndonesiaIndonesia

Study design:Study design:– Control: training onlyControl: training only– Training plus self Training plus self

assessmentassessment– Training, self Training, self

assessment, plus assessment, plus peer reviewpeer review

Assessments at Assessments at baseline, 1, and 4 baseline, 1, and 4 monthsmonths

0

5

10

15

20

25

30

35

40

base

line

1 m

onth

4 m

onth

s

controlselfself/peer

0%

20%

40%

60%

80%

100%

Jun-97 Dec-97 Jun-98 Dec-98

Per

cen

t co

mp

lian

ce

HW checked 1danger sign

Weight/age checked

Counseling onmedications

Vaccination statuschecked

Feedback

Feedback

Feedback

Strategies for Promoting Strategies for Promoting Compliance with Compliance with

GuidelinesGuidelines

Systematic design of job aidsSystematic design of job aids– IMCI recording formIMCI recording form– Critical pathways for EOC Critical pathways for EOC – Client memory aid for antibioticsClient memory aid for antibiotics– Instructions for malaria diagnostic testInstructions for malaria diagnostic test

Managed incentive systemsManaged incentive systems– materialmaterial– non-materialnon-material

Personnel systemsPersonnel systems

Quality Quality Improvement/Problem Improvement/Problem

SolvingSolving

Industrial model: quality management, Industrial model: quality management, TQM, CQITQM, CQI

Widely used in US, other DCsWidely used in US, other DCs Expanding use in LDCs; hundreds of Expanding use in LDCs; hundreds of

local applicationslocal applications Provides a framework for problem Provides a framework for problem

solvingsolving Intangible benefit: change in attitude Intangible benefit: change in attitude

toward problems, “culture of quality”toward problems, “culture of quality”

Salima: Improving Patient Salima: Improving Patient Compliance-MalariaCompliance-Malaria

Problem: high rate Problem: high rate of malaria “re-of malaria “re-attendants”attendants”

Team’s analysisTeam’s analysis– 23% of malaria 23% of malaria

patients returnedpatients returned– 84% forgot 84% forgot

instructionsinstructions– Evidence of Evidence of

discarded drugs discarded drugs

InterventionsInterventions– directly observed directly observed

dose of SPdose of SP– educate educate

community on community on treatment treatment instructionsinstructions

– Blood smear for all Blood smear for all re-attendantsre-attendants

Re-attendant Malaria Re-attendant Malaria Patients in Salima Clinic, Patients in Salima Clinic,

MalawiMalawi

0

5

10

15

20

25

Feb March April May June July

% re-attendant

Blantyre, Malawi: Blantyre, Malawi: Preparing for IMCI Preparing for IMCI ImplementationImplementation

Problem identified: provider time with Problem identified: provider time with patients too brief for IMCI, waiting patients too brief for IMCI, waiting times already longtimes already long

Data collection: client flow, staff time Data collection: client flow, staff time Interventions tested:Interventions tested:– reorganized registration systemreorganized registration system– changed staffing patternchanged staffing pattern– introduced one-way flow for patientsintroduced one-way flow for patients– lunch hour changeslunch hour changes

Results: Increased Contact Time and Decreased Waiting

1.8 6.3

80.2

39.2

0

10

20

30

40

50

60

70

80

90

Contact time Waiting time

April-00

Dec-00

Study 2: Problem-Solving Study 2: Problem-Solving Teams InterventionTeams Intervention

Supervisors from 2 districts trained and Supervisors from 2 districts trained and coached 23 facility-based teams coached 23 facility-based teams

Teams problem-solve using simple quality toolsTeams problem-solve using simple quality tools

Teams assigned the problem of improving IMCI Teams assigned the problem of improving IMCI performance, but selected own solutions to performance, but selected own solutions to implementimplement

Solutions ImplementedSolutions Implemented by Teams by Teams

0 5 10 15

Proper duty allocation

Regular practice

Monthly meetings

Change pt. flow

Share workload

Pt. IMCI education

On-job training

Clocking-in register

Procure IMCI drugs

Number of teams

Improvement Trends in IMCI Improvement Trends in IMCI Case Management,* 1998-Case Management,* 1998-

20002000

0

10

20

30

40

50

60

70

No teams (n**=14)

Low teams(n=15)

High teams(n=6)

*Based on composite index of 4 aspects: assessment, classification, treatment, counseling**n=number of facilities

Pe

rce

nta

ge

po

int

imp

rov

eme

nt

Quality Quality Improvement/Problem Improvement/Problem

SolvingSolving

Remaining issues:Remaining issues:– weak documentation by most teamsweak documentation by most teams– potential for wider use of local team potential for wider use of local team

experiencesexperiences– need for increased focus on clinical careneed for increased focus on clinical care– cost-effectiveness comparison of CQI with cost-effectiveness comparison of CQI with

streamlined methodologiesstreamlined methodologies– incentives for teamsincentives for teams– longitudinal evaluationslongitudinal evaluations

The Design of Health The Design of Health ServicesServices

How the work of staff, performing How the work of staff, performing different sets of tasks is organizeddifferent sets of tasks is organized

The design of a “system of care” for a The design of a “system of care” for a given condition can include community given condition can include community through referral hospitalthrough referral hospital

Re-design: if current design doesn’t Re-design: if current design doesn’t make sensemake sense

Relationship to QI: fixing specific Relationship to QI: fixing specific problems vs. starting overproblems vs. starting over

The Design of Health The Design of Health ServicesServices

Methodology: a stepwise process for Methodology: a stepwise process for incorporating the views of stakeholders incorporating the views of stakeholders within resource constraintswithin resource constraints

LAMM initiative: EOCLAMM initiative: EOC May be useful when introducing new May be useful when introducing new

clinical standards, like IMCIclinical standards, like IMCI Tver, Russia: re-design of system of Tver, Russia: re-design of system of

care of neonates to implement new care of neonates to implement new EBGs:EBGs:

Key Results of (Re)Designing the Key Results of (Re)Designing the System of Neonatal Care in TverSystem of Neonatal Care in Tver

93% 7-day survival rate after initial 93% 7-day survival rate after initial resuscitationresuscitation

46% increase in neonates transported 46% increase in neonates transported to NICU with normal body temperatureto NICU with normal body temperature

63% reduction in neonatal mortality 63% reduction in neonatal mortality due to RDSdue to RDS

Regulatory StrategiesRegulatory Strategies

Major examples: Major examples: – Accreditation of facilities and training Accreditation of facilities and training

programsprograms– Certification of specialized competenciesCertification of specialized competencies– Licensing of professionals and hospitalsLicensing of professionals and hospitals

Based on transparent, external Based on transparent, external evaluation of care or competenceevaluation of care or competence

Usually periodic, time -limited Usually periodic, time -limited Assessment has consequencesAssessment has consequences

Regulatory StrategiesRegulatory Strategies

Accreditation and certification not limited Accreditation and certification not limited to government bodiesto government bodies

Provides consumers with a “report card”Provides consumers with a “report card” Limited alternatives for influencing quality Limited alternatives for influencing quality

in the private sectorin the private sector LDC programs expandingLDC programs expanding Recent innovations in DCs:Recent innovations in DCs:

– re-testing for licensingre-testing for licensing– assistance to improve vs. punitive action assistance to improve vs. punitive action

Whether Mystery Shoppers Whether Mystery Shoppers Were Sold Correct DrugsWere Sold Correct Drugs

22.2

60.1

17.7

32.5

65.6

2

0%

20%

40%

60%

80%

100%

Intervention Control

Correct type*

Incorrect type

Nothing sold

(Shoppers=203) (Shoppers=302)

*Correct type was defined as an effective SP plus an antipyretic. Significant difference at p<.000.

Issues for DiscussionIssues for Discussion

Organization of QA activities that Organization of QA activities that are accountable for resources used are accountable for resources used and resultsand results

Evaluation of QA programsEvaluation of QA programs Relationship of cost and qualityRelationship of cost and quality Potential contribution of human Potential contribution of human

resources approaches resources approaches Role of the community in QARole of the community in QA

Issues for DiscussionIssues for Discussion

QA and health reform issues such QA and health reform issues such as decentralization and financingas decentralization and financing

Applications to HIV/AIDS, TB, and Applications to HIV/AIDS, TB, and anti-microbial resistanceanti-microbial resistance

QA in pre-service trainingQA in pre-service training Role of international lendersRole of international lenders Patient satisfaction and utilizationPatient satisfaction and utilization