Improving health services at the community level
While improvement methods have been widely applied to clinical health care, there is a growing body of evidence for the application of improvement methods to community-level health and social services and to health system issues such as community health worker performance management, supply chain management to the “last mile”, information systems, and financial management (Heiby 2014).
These experiences indicate that community-based and community-led improvement approaches hold great promise for increasing access to priority services, as well as their coverage, effectiveness and people-centeredness. In particular, community-participatory or community-led improvement efforts can help build community engagement and ownership of health services, including development of locally feasible and sustainable solutions to common bottlenecks.
Basic principles of improvement—understanding care processes, making changes to those processes, and using data to track progress—have proven relevant and feasible for community-level improvement interventions and improvement teams. Maps and simple flow charts using pictures or photographs and pictorial ways to convey quantitative results can be readily understood by team members with low literacy.
Like facility-based efforts, community quality improvement efforts benefit from the clear definition of measurable improvement aims based on evidence-based, high-impact interventions for important health problems. Such improvement aims need to be complemented by clear definitions and feasible measurement approaches to track process and outcome measures toward achieving the defined aims and regular testing of changes to processes of care to deliver the best practices. For example, improving and sustaining adherence to post-partum home-based newborn care best practices (i.e., identification and management of danger signs, counseling, support for exclusive breastfeeding) requires clarity about the improvement aim and a clear statement of how progress (or lack of progress) toward the aim will be measured.
One difference between facility and community-level improvement efforts is who participates on improvement teams. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) found that orienting and gaining buy-in from community members and leaders and asking them to decide who would be the quality improvement team members was critical for community engagement. Engaging community leaders in support of improvement efforts is essential to gain credibility and community participation. Unlike in a facility, where the staff is subordinate to the facility head and improvement work can be considered part of their regular job duties, community involvement in improvement requires buy-in by leaders, who can then convince the community that the improvement effort is a worthwhile and necessary effort (Stover et al. 2014).
Many successful community and facility-based improvement efforts create quality improvement (QI) teams that include community stakeholders, clients, community health workers, and facility-based providers. Such mixed teams may be particularly effective for building linkages between community and facility services and for improving people-centered care, co-defined by providers and clients and their families. Much of the power of improvement interventions is their focus on continuous change and measurement toward a clear aim. This focus provokes new ways of thinking about how programs and services can be organized to achieve effective, safe, equitable, and people-centered care. Thinking more systematically and purposefully about change, what change might be possible (as opposed to just working harder, applying more resources, or hoping for the best), and how to measure the effects of change for achieving important health and social outcomes is at the heart of improvement.