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