A National Organizational Assessment (NOA) to Build Sustainable Quality Management Programs in Low- and Middle-Income Countries

Development of the National Policy for Quality in Healthcare for Malaysia

BACKGROUND

Quality in healthcare is a fundamental pillar of health systems performance, leading to improved health outcomes and reduced waste. The World Health Organization recommends that countries establish a national quality policy and strategy (NQPS) to steer the provision of safe and high-performing healthcare services and foster a quality culture. This paper describes the development process and key content of Malaysia's new 5-year National Policy for Quality in Healthcare.

METHODS

The development process was managed by a technical working group led by the Institute for Health Systems Research in the Ministry of Health. Situational analysis was conducted through a multi-pronged approach, underpinned by a review of the past and present healthcare sectoral and quality plans and guided by the WHO NQPS framework. This approach involved: (i) review of quality-related policy documents, (ii) online surveys of healthcare providers and the public, (iii) key-informant facilitated discussions and (iv) mapping of existing quality improvement initiatives (QIIs). Data gathered from these approaches informed the content of the new policy. Following thematic analysis, the findings were grouped into specific domains, which were then organized into a strengths, weaknesses, opportunities, and threats (SWOT) framework.

RESULTS

Ten key areas of concern identified were (i) a people-centred holistic approach, (ii) governance for quality, (iii) resources, (iv) quality culture, (v) stakeholder engagement, (vi) health management information system, (vii) workforce competency, (viii) knowledge exchange, (ix) quality indicators and (x) monitoring and evaluation of quality activities. These led to the formulation of seven strategic priorities  for the planning of improvements aimed at addressing the key areas of concern. The national definition of quality was affirmed. A total of 40 QIIs were mapped and grouped into three broad categories, namely (i) regulatory, (ii) domain-specific QIIs and (iii) Quality Improvement (QI) method.

CONCLUSIONS

The National Policy for Quality in Healthcare for Malaysia was developed through a comprehensive situational analysis using a multi-method approach that identified priorities across national, state, institutional and community levels. This evidence-informed approach led to meaningful contextual adaptation of the NQPS framework to shape the strategic direction to advance quality and achieve effective and safe outcomes for all Malaysians.

Do Quality Improvement Initiatives Improve Outcomes for Patients in Antiretroviral Programs in Low- and Middle-Income Countries? A Systematic Review

BACKGROUND

There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes.

METHODS

We conducted a systematic review adhering to PRISMA guidelines (PROSPERO ID: CRD42017071848), searching PubMed, MEDLINE, Embase, Web of Science, and the Cochrane database of controlled trials for articles reporting on the effectiveness of QI and quality assurance initiatives in HIV programs in low- and middle-income countries in relation to ART uptake, retention in care, adherence, viral load suppression, mortality, and other outcomes including cost-effectiveness and long-term sustainability.

RESULTS

One thousand eight hundred sixty articles were found, of which 29 were included. QI approaches were categorized as follows: (1) health system approaches using QI methods; (2) QI learning networks including collaboratives; (3) standard-based methods that use QI tools to improve performance gaps; and (4) campaigns using QI methods. The greatest improvements were seen in ART uptake [median increase of 14.0%; interquartile range (IQR) -9.0 to 29.3], adherence [median increase of 22.0% (IQR -7.0 to 25.0)], and viral load suppression [median increase 26.0% (IQR -8.0 to 26.0)].

CONCLUSIONS

QI interventions can be effective in improving clinical outcomes; however, there was significant variability, making it challenging to identify which aspects of interventions lead to clinical improvements. Standardizing reporting and assessment of QI initiatives is needed, supported by national quality policies and directorates, and robust research.

Improving the cascade of global tuberculosis care: moving from the "what" to the "how" of quality improvement

Tuberculosis is preventable, treatable, and curable, yet it has the highest mortality rate of infectious diseases worldwide. Over the past decade, services to prevent, screen, diagnose, and treat tuberculosis have been developed and scaled up globally, but progress to end the disease as a public health threat has been slow, particularly in low-income and middle-income countries. In these settings, low-quality tuberculosis prevention, diagnostic, and treatment services frustrate efforts to translate use of existing tools, approaches, and treatment regimens into improved individual and public health outcomes. Increasingly sophisticated methods have been used to identify gaps in quality of tuberculosis care, but inadequate work has been done to apply these findings to activities that generate population-level improvements. In this Personal View, we contend that shifting the focus from the "what" to the "how" of quality improvement will require National Tuberculosis Programmes to change the way they organise, use data, implement, and respond to the needs and preferences of people with tuberculosis and at-risk communities.

Implementing quality improvement in tuberculosis programming: Lessons learned from the global HIV response

The quality of care and treatment for tuberculosis (TB) is a major barrier in global efforts to end TB as a global health emergency. Despite a growing recognition of the need to measure, assure, and improve quality of TB services, implementation of quality improvement (QI) activities remains limited. Applying principles of systems thinking, continuous measurement, and root cause analysis, QI represents a proven approach for identifying and addressing performance gaps in healthcare delivery, with demonstrated success in low- and middle-income settings in the areas of HIV/AIDS, maternal, newborn, and child health, and infection control, among others. Drawing from lessons learned in the development of QI programming as part of the global response to HIV, we review key enablers to implementation that may assist NTPs in turning aspirations of high-quality service delivery into action. Under the umbrella of a formal quality management (QM) program, NTPs' attention to planning and coordination, commitment to tracking key processes of care, investment in QI capacity building, and integration of TB QI activities within efforts to advance universal health coverage provide a framework to sustainably implement QI activities.