Improving the quality of health care across the health system

National Quality Policy and Strategy of the Health Services in Health Systems of Developing Countries: A Scoping Review

It has always been argued that countries should not be inactive about the quality of health services. Therefore, a clear policy needs to be created regarding how quality of health services should be. The present scoping review was aimed to identify and map the available evidence regarding the National Quality Policy and Strategy (NQPS) of the health services in health systems of developing countries, graphically and tabularly. We followed the published methodological guidance of the Joanna Briggs Institute reviews. Also, we employed a narrative thematic synthesis integrated with the systematic analysis using the World Health Organization's approach of NQPS, and the multiple-streams framework of Kingdon. We included 33 records that met the inclusion criteria; these records were published between 2010 and 2019. Meanwhile, government documents were the most frequent records (61%). Zimbabwe, Indonesia, and Sudan were the most frequent locations (each one 8%). The Ministry of Health was in charge of the ultimate responsibility for developing the NQPS in all identified countries. Besides, 82% of the countries were in the development phase of NQPS formulation, and convergence of three streams was observed in Indonesia, Sudan, and Tanzania. It seems that the African countries were informed about their quality issues, and the need for having NQPS have been more popular with them. We recommend that future research focuses on examining NQPS in terms of prioritizing in the agenda-setting phase of the policy-making cycle, and also, document analysis of all identified NQPS based on the core eight interdependent elements related to the NQPS approach.

Quality and safety of care: Moroccan experience

Background

The Ministry of Health and Social Protection (MOHSP) of the Moroccan Kingdom acknowledges the crucial need to improve the quality and safety of care provided to patients. As a result, they have launched a process that involves, developing a conceptual framework and implementing national health policies aimed to enhance services offered to hospital users.

Objective

The aim of this study is to identify all the approaches developed by the MOHSP since 1990 to enhance the quality and safety of care.

Materials and Methods

This study is a descriptive qualitative analysis. The data was collected over a six-month period, through semi-structured interviews with professionals reporting to the MOHSP, and through a document analysis.

Results

The results provide a comprehensive description of approaches to quality and safety of care in the Moroccan health system, the findings reveal that these approaches are based on three complementary strategies: continuous quality improvement, standardization, and safety of care.

Conclusions

The Moroccan health system has implemented various strategies to improve the quality and safety of care. However, these strategies have not been sustained due to several factors. To ensure sustainability, the system needs to invest in capital and resources, involve quality experts in hospitals, use processbased approaches, strengthen legislation and regulations related to quality of care, and translate them into implementing decrees.

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India

BACKGROUND

With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival.

METHODS

The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated.

RESULTS

Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%.

CONCLUSION

The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Aiming for quality: a global compass for national learning systems

INTRODUCTION

Transforming a health system into a learning one is increasingly recognized as necessary to support the implementation of a national strategic direction on quality with a focus on frontline experience. The approach to a learning system that bridges the gap between practice and policy requires active exploration.

METHODS

This scoping review adapted the methodological framework for scoping studies from Arksey and O'Malley. The central research question focused on common themes for learning to improve the quality of health services at all levels of the national health system, from government policy to point-of-care delivery.

RESULTS

A total of 3507 records were screened, resulting in 101 articles on strategic learning across the health system: health professional level (19%), health organizational level (15%), subnational/national level (26%), multiple levels (35%), and global level (6%). Thirty-five of these articles focused on learning systems at multiple levels of the health system. A national learning system requires attention at the organizational, subnational, and national levels guided by the needs of patients, families, and the community. The compass of the national learning system is centred on four cross-cutting themes across the health system: alignment of priorities, systemwide collaboration, transparency and accountability, and knowledge sharing of real-world evidence generated at the point of care.

CONCLUSION

This paper proposes an approach for building a national learning system to improve the quality of health services. Future research is needed to validate the application of these guiding principles and make improvements based on the findings.

"All about the money?" A qualitative interview study examining organizational- and system-level characteristics that promote or hinder shared decision-making in cancer care in the United States

BACKGROUND

Despite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. Organizational and health system characteristics appear to contribute to the difficulties in implementing SDM in routine care. However, little is known about the relevance of the different characteristics in specific healthcare settings. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care.

METHODS

We conducted semi-structured interviews with diverse cancer care stakeholders in the USA. Of the 36 invited, 30 (83%) participants consented to interview. We used conventional content analysis to analyze transcript content.

RESULTS

The dominant theme in the data obtained was that concerns regarding a lack of revenue generation, or indeed, the likely loss of revenue, were a major barrier preventing implementation of SDM. Many other factors were prominent as well, but the view that SDM might impair organizational or individual profit margins and reduce the income of some health professionals was widespread. On the organizational level, having leadership support for SDM and multidisciplinary teams were viewed as critical to implementation. On the health system level, views diverged on whether embedding tools into electronic health records (EHRs), making SDM a criterion for accreditation and certification, and enacting legislation could promote SDM implementation.

CONCLUSION

Cancer care in the USA has currently limited room for SDM and is prone to paying lip service to the idea. Implementation efforts in US cancer care need to go further than interventions that target only the clinician-patient level. On a policy level, SDM could be included in alternative payment models. However, its implementation would need to be thoroughly assessed in order to prevent further misdirected incentivization through box ticking.

Institutionalizing quality within national health systems: key ingredients for success

Quality improvement initiatives can be fragmented and short-term, leading to missed opportunities to improve quality in a systemic and sustainable manner. An overarching national policy or strategy on quality, informed by frontline implementation, can provide direction for quality initiatives across all levels of the health system. This can strengthen service delivery along with strong leadership, resources, and infrastructure as essential building blocks for the health system. This article draws on the proceedings of an ISQua conference exploring factors for institutionalizing quality of care within national systems. Active learning, inclusive of peer-to-peer learning and exchange, mentoring and coaching, emerged as a critical success factor to creating a culture of quality. When coupled by reinforcing elements like strong partnerships and coordination across multiple levels, engagement at all health system levels and strong political commitment, this culture can be cascaded to all levels requiring policy, leadership, and the capabilities for delivering quality healthcare.

A programme to improve quality of care for patients with chronic diseases, Kazakhstan

Objective

To evaluate the effect of a disease management programme in Kazakhstan on quality indicators for patients with hypertension, diabetes and chronic heart failure.

Methods

A supportive, interdisciplinary, quality improvement programme was implemented between November 2014 and November 2015 at seven polyclinics in Pavlodar and Petropavlovsk. Quality improvement teams were established at each clinic and quality improvement tools were introduced, including patient flowsheets, decision support tools, patient registries, a patient recall process, support for patient self-management and patient follow-up with intensity adjusted for level of disease control. Clinic teams met for four 3-day interactive learning sessions within 1 year, with additional coaching visits. Implementation was managed by five local coordinators and consultants trained by international consultants. National and regional steering committees monitored progress.

Findings

Between July and October 2015, the proportion of hypertensive patients with the recommended blood pressure increased from 24% (101/424) to 56% (228/409). Among patients with diabetes, the proportion who recently underwent eye examinations increased from 26% (101/391) to 71% (308/433); the proportion who had their low-density lipoprotein cholesterol measured increased from 57% (221/391) to 85% (369/433); and the proportion who had their albumin : creatinine ratio measured increased from 11% (44/391) to 49% (212/433). The proportion of chronic heart failure patients who underwent echocardiography rose from 91% (128/140) to 99% (157/158). All patients set themselves self-management goals.

Conclusion

This intensive, supportive, multifaceted programme was associated with significant improvements in quality of care for patients with chronic disease. Further investment in coaching capacity is needed to extend the programme nationally.

Quality improvement in maternal and newborn healthcare: lessons from programmes supported by the German development organisation in Africa and Asia

Improving the quality of maternal and child healthcare (MCH) is a mandatory step on the path to reaching the Sustainable Development Goals and Universal Health Coverage. Quality improvement (QI) in MCH is a strong focus of the bilateral development cooperation provided by Germany to help strengthen the health systems of countries with high maternal and child mortality rates and/or with high unmet needs for family planning. In this article, we report on the findings of an analysis commissioned by a community of practice on MCH, of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The objectives were to review the QI interventions implemented through programmes which have received technical assistance from GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development in 14 Asian and African countries, to identify and describe the existing approaches and their results, and finally to draw lessons learnt from their implementation. Our analysis of the information contained in programme documents and reports identified five main methodologies used to improve the quality of care: capacity-building and supervision, governance and regulation, systemic QI at facility level, support to infrastructures, and community support. It is difficult to attribute the observed progresses in maternal and neonatal health to a particular agency, programme or intervention. We acknowledge that systemic implementation research embedded within the programmes would facilitate an understanding of the determinants of successful QI interventions, would better assess their effectiveness, and therefore better guide future bilateral aid programmatic decisions.