regional centre for quality of health care, uganda quality of care in developing countries dr...

Regional Centre for Quality of Health Care, Uganda

Quality of Care in Developing Countries

Dr Chilunga PutaDisease Control Priorities in East Africa

Kilimanjaro Kempinsky Hotel, Dar es Salaam

21-23 August, 2007


Objectives of Presentation

This presentation will elaborate: The definition of quality A framework for quality of care Policy interventions to improve

quality Measurement of quality Economic benefits and costs of

quality


Defining Quality Health CareGroup Exercise

What is quality health care? Take a few minutes to reflect on the

meaning of quality write your own definition on a VIPP

card Stick the card on the wall What picture emerges from the various

definitions?


A Definition of Quality… ‘The degree to which health

services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (Institute of Medicine, 2001)

Institute of Medicine, 2001: Crossing the Quality Chasm, Washington, DC: National Academy Press


Elements of Quality -1

Quality comprises three elements: Structure

Stable material characteristics (infrastructure, tools, technology)

Resources of the organization Financing of care


Elements of Quality-2

Quality comprises three elements: Process

transformation of inputs from the health care system into health outcomes


Elements of Quality-3

Quality comprises three elements: Outcomes

health status Deaths morbidity Disability adjusted years Patient satisfaction or responsiveness

to the health care system


Elements of Quality - 4

Structure In most developing countries:

Shortages of medical staff Shortages of medical supplies such as medication

Inadequate facilities and poor infrastructure



Structure cont. Evidence suggests weak link

between structural elements and health outcome except where physical improvements:

Increase access or Increase volume of a clinical

procedure


Elements of Quality - 6 Process (interaction between caregiver

and patients) Can be measured with every visit but

sometimes difficult to measure because:

Consultations are private Lack of measurement criteria reliable measurement tools may not be available



Process cont. New methods being developed

to provide valid measures of clinical practice

Evidence is emerging for which process measures lead to better health outcomes



Process cont. Combination of ubiquity,

measurability and linkage to health outcomes makes measurement of process the preferred way to assess quality


Elements of Quality - 9 Contextual elements illuminating

how process changes can improve care include:

Patient safety Effectiveness Patient centeredness Timeliness Efficiency Equity


Elements of Quality - 10 Outcomes

Not an efficient way to measure quality

Patients can still recover even if they get poor quality care

Patients can fail to recover even if they get good quality of care

Adverse health outcomes do not occur with every encounter


Perspectives of Quality

Quality can be assessed from different view points: Health care provider perspective

(technical/professional) Patient perspective Community perspective Health financier perspective Administrative perspective etc.


Patient Perspective 1

Determined by: Individual characteristics that

affect Compliance Follow –up decisions Long-term lifestyle changes


Patient Perspective 2 Patient access and utilization

affected by Interpersonal relationships Cultural appropriateness Gender sensitivity

Patient satisfaction and patient responsiveness are therefore important outcome measures


Technical/Professional Perspective

Strives to meet normative standards

Adherence to evidence-based criteria

Have evidence based quality criteria linked to better health outcomes


Quality of Care Framework

Demographic/socioeconomic factors

Health care access

Health Policy Reforms

Structure Process Health

outcome

The Quality of Care

Institutional factors

Social Factors

Cultural Factors

Political Factors

Ref: Peabody et al 1999


What Causes Poor Quality of Care?

Economic constraints (evidence suggests this contributes about 37 %)

Poor process (as much as 60%)

Other causes

Conclusion: it is beneficial to focus on processes


Evidence for Poor Processes

Nolan et al 2001: seven country study: 75% cases not adequately diagnosed,

treated, or monitored

DCP study of five developing countries: Within country range of quality of doctors

10x as great as between country range



RCQHC review of health worker performance:

Uganda (2 districts, 6 diagnostic centers for TB)

29% of the staff partly knew the treatment categories; 18% not sure; 53% did not know



6% of staff knew all the treatment regimens recommended by NTLP; 29% knew the regimens for cases on re-treatment only; and 65% of the staffs were not sure

24% of the staff adequately knew the case description of a TB suspect; 47% were not specific and 29% did not know


Policy Interventions for Quality of Care

Quality improvement policy:one that has ability to raise level of health and reduce variations in quality


Policy Interventions for Quality of Care

Two types of policy: Those that influence provider behaviour

by addressing Structural conditions Finance Design or re-design of health systems

Those that directly target provider behaviour individually or collectively


Policy: Changing Structural Conditions

Two components of structure influences process:

Organization

Finance



These influence process by changing the health care system: Socioeconomic, Legal, Administrative, Cultural, and Information context



Policy focus area: Legal mandates, accreditation and administrative regulations

Control entrance into practice of health care

Determines what functions health workers can legally perform


Policy: Changing Structural Conditions Policy focus area: Legal mandates,

accreditation and administrative regulations

Periodic hospital accreditation has potential to provide pressure for improvement

No evidence that these policies actually improve performance and health outcomes



Policy focus area: Malpractice litigation to enforce legal mandate

To promote quality there must be adequate legal and judicial systems


Policy: Changing Structural Conditions Policy focus area: Professional

oversight Peer review

Requires adequate data to inform improvement processes

Evidence for improved performance where workers are reviewed


Policy: Changing Structural Conditions Policy focus area: Professional

oversight Can become “quality by inspection” leading to

Antagonistic relationships between workers and managers

Preclusion of cooperate problem solving


Policy: Changing Structural Conditions Policy focus area: National and local

clinical guidelines Should be evidence based Resource constraint may necessitate modification of guidelines

Include physicians in development and review of guidelines


Policy: Changing Structural Conditions Policy focus area: Sharing Information

on Quality Improvement Technology Potential to accelerate the scale up of quality practice

Can help develop a system of effective research to improve quality of care

Promotes development of tools and articles for quality improvement



Policy focus area: Public Private Provision of Care

Private sector provide significant amounts of care in developing countries

Public regulatory framework can lead to private provision of higher quality care e.g. Senegal (preventive nutrition services)



Policy focus area: Targeted Education and Professional Re-training

Targeted learning, case-based learning, interactive teaching techniques have had success in improving health outcomes e.g. TZ reduction in under five mortality within 2 years by training in control of acute respiratory infections



Policy focus area: Organizational Change Develop organizational and individual capabilities where they have greatest impact on the process of care

Better care is the product of many processes working together so isolated improvements will not succeed



Policy focus area: Organizational Change

Models of organizational change: Total Quality Management Collaborative improvement model

Plan-Do-Study-Act-cycle (PDSA) Internal enabling environment



Total Quality Management (Continuous improvement) Cycle of planning, implementing, evaluating and revising to improve



Techniques include process mapping, statistical control and structured team activities

Example: Malawi NTP has successfully applied TQM to TB control processes



Collaborative improvement cycle

Facilitates scale up of quality improvement initiatives

Aims at continuous organizational and individual performance



Collaborative improvement cycle Has 4 elements:

Definition of aimMeasurement



InnovationTesting whether innovation meets original aim

Currently being used in Uganda for HIV/AIDS program improvement



Plan-Do-Act cycle (PDSA) Action –oriented learning Teams go through the cycle

together to identify appropriate improvement methods

Useful for design and redesign of systems



Internal Enabling Environment Creation of enabling environment calls

for: Leadership and leadership training for QI Resources for QI

Can be made by teams of individuals or a strong leader with interest in teamwork/QI


Policy: Directly Affecting Provider practice Performance based feedback

Addresses solitary nature of clinical practice

Rewards high quality care Increases knowledge about

appropriate action Can form basis for system wide

incentives for improving quality of care


Policy: Directly Affecting Provider practice Training with Peer Review

feedback Re-training in specific areas of

medical practice, with peer review feedback ahs been shown to improve practice in Mexico city

Uses interactive training workshops and a managerial peer review committee


Policy: Directly Affecting Provider practice Performance-Based Remuneration

Direct payments to providers meeting quality standards (based on process indicators associated with favorable patient outcomes) –used in USA: 3-10 % of provider’s compensation

Potential for accelerating quality improvement


Policy: Directly Affecting Provider practice High Volume of Care

High volume of care by individuals give opportunity to experience and practice through repetition, this leads to

fewer complications Less resource use Better quality for a variety of procedures e.g. cataract operations


Policy: Directly Affecting Provider practice Performance Based Professional

Recognition Public recognition,

administrative privileges, and wards from professional bodies in recognition of good performance can promote QI (e.g. Uganda yellow star program)


Policy and Changes in Practice

Need to measure quality to Create and demonstrate links between policy and changes in practice


Policy and Changes in Practice

Measures of quality must be Valid and reliable Easily understood Inexpensive to obtain Resistant to manipulation Related to better health

outcomes


What is measured? Structure:

measured in terms of equipment, staffing levels, budgets and expenditures, drugs, supplies, service utilization-

correction of these have not been directly linked to changes in health outcome;


What is measured?

Structure: more useful parameters such as patient flow, patient referral systems and pricing of services are not usually available


What is measured?

Process: five approaches: Chart abstraction (review of the

medical record): suffer from reliability and accuracy of information; lack of detailed information and legibility; Electronic Medical Record being tried out to counter these problems


What is measured?

Direct observation and recording visit: suffers from participant bias - ethics require that the provider and the must be informed


What is measured?

Administrative Data: lack sufficient clinical detail and often inaccurate – one study (Peabody et al. 2004 found actual clinical diagnosis was only reflected 57% of the time!)


What is measured? Standardized patients (mystery patients):

gold standard: reliable over a range of conditions;

provide valid measures that capture variations in clinical practice among providers over time;

expensive; useful only for adult conditions, and only

those that can be simulated;


What is measured?

Clinical Vignette: Measures quality within a group of

providers Evaluates quality at the population level Responsive to variations in quality Providers accept them readily if anonymity

is assured Can be administered on paper, by

computer and over the internet


What is measured? Clinical Vignette cont.:

Each provider is presented with the same case or cases (no case mix adjustments)

Use open ended questions and interactive responses that simulate the visit and evaluate the physicians knowledge

Predictive validity for processes more consistent than with abstracted medical record


What is measured?

Clinical Vignette cont.: Each provider is asked to

Take a history Do an examination Order the necessary tests Make a diagnosis Specify a treatment plan


What is measured?

Clinical Vignette: Useful for

Comparative studies Evaluating policy interventions (pre- and post-)

Saving costs: inexpensive and easy to score (useful for developing countries)


Economic Benefits

Individual: Physical, emotional and mental health Increased productivity (higher capacity

to generate income, other things being equal)

Higher quality prenatal and post natal care decreases mortality and improves subsequent school performance (labour productivity) (Van der Gag, 2000)


Economic Benefits

Social: Greater capacity to generate wealth Reduces premature death and

disability (labour force and productivity up)

Lower costs for providers and health insurers (lower public expenditure and possibly lower premiums)


Correlation between Health outcomes and Economic Growth

Malaria slows economic growth by 1-2 % per year (Sachs, 2001)

One year increase in life expectancy results in GDP growth rate of 1-4 % (Bloom, Canning and Sevilla, 2001)

QI can give up to 5%annual reduction in child mortality rates (equiv. to economic gain in 50 Yrs of 18% GDP (Peabody et al. 2006)


Economic Costs of QI

Direct costs Human and physical resources for

implementation Indirect costs

Subtle changes e.g. Changes in quantity of health services Provider demands for various inputs Changes in market prices


Economic Costs of QI

Macro Level Costs Nationwide training of health providers Changing payment systems Developing consumer policies to

protect consumers against malpractices

These will affect national budgetary allocations


Cost-effectiveness of Improved Process

Peabody et al (2006) give 2 evidence based examples of cost-effectiveness (limited data) Better treatment of pneumonia based

on two studies (Kelley et al., 2001; Stansfield and Shepard, 1990): an intervention that raises quality, has a cost-effective ratio of US$132:US$800 per life saved


Cost-effectiveness of Improved Process

Better treatment of diarrhoea (using cheaper ORT and not antibiotics): improved practice increased the proportion of cases treated correctly from 16% to 48% (Bloom Canning and Sevilla, 2001) - taking a number of studies into consideration, effectiveness ratio is estimated at 80%


Research and Quality

Why research? Documentation of correlates between

quality and: providers, health care systems, whole populations

Testing of specific indicators of the dimensions of quality

Compare measurement approaches to determine most useful


Research and Quality Why research?

Compare policy alternatives Determination of what the health

system is contributing to society and at what cost

Quantifying cost of different monitoring and QI approaches

Determining effects of policy on quality of care on provider behaviour and impact on health outcomes


Research and Quality

Why research? Need data on how different

remuneration and contracting policies impact for example on the brain drain in developing countries

In summary we need a stronger evidence base for quality of care in developing countries especially Africa


Summary Good quality: providers able to

manage health care by timely, skillful application of medical technology in a culturally sensitive manner, within the resource constraints

Good quality leads to: Better health outcomes In the long term economic development


Summary Poor quality is wasteful and can be

harmful Quality has been largely ignored

where it is needed most! The process of care in dev.

Countries is poor, but it can be improved in the short term, given a favorable policy environment


Summary

Comparative research on processes and outcomes should be explicitly encouraged

Dissemination of empirical findings on quality variations must be done to facilitate the learning process

regional centre for quality of health care, uganda quality of care in developing countries dr...

Documents

quality of health care

uganda quality of care

uganda elements of quality

definition of quality

quality chasm

meaning of quality

costs of quality slide

health care system slide