Organization of work

Organizational interventions are often used to facilitate and reinforce health care performance in accordance with standards (Marquez 2001). Such interventions provide additional resources or equipment; introduce organizational changes, such as redistribution of tasks; or redesign processes to embed measures to facilitate correct performance or prevent incorrect performance. Principal advantages of these interventions are that they are usually inexpensive and under the control of managers.

Increasing concern with preventable medical errors has fostered support for organizational interventions. An Institute of Medicine report on ways to reduce medical errors strongly advocated process redesign to simplify and standardize key health care processes and to design tasks in ways that ensure safety and facilitate correct performance (Kohn et al. 1999). Key principles of such process redesign efforts are to avoid reliance on memory and use of constraints or forcing functions that guide the health care provider to the next appropriate action to make it hard to do the wrong thing. An example of this type of constraint is the auto-disable syringe, which is designed to jam up after one injection to prevent its re-use.

Organizational interventions to improve work processes play a prominent role in much of health care quality improvement activities in LMIC, but often have not been subject to rigorous evaluations of their effectiveness. The USAID-supported Maximizing Access and Quality Initiative identified a set of guiding principles to improve the organization of health care delivery (Population Reports 2004):

  • Use evidence-based practices to provide effective health care efficiently.
  • Improve links with other services and delivery sites so that clients can obtain care appropriate to each level of the health care system.
  • Minimize paperwork and maximize information use.
  • Pay attention to the physical factors of service delivery, which include supplies, equipment, and workspace.
  • Tailor service hours and schedules to meet both clients' and providers' needs.
  • Examine client flow to make sure waiting times are minimized, giving more time for clients to interact with providers.
  • Define division of labor and job responsibilities to let staff know what is expected and to enable them to make decisions and take action.
  • Consider social factors, such as good supervision, to motivate and support staff and encourage skill development.

Text box: Strengthening Health Facility Capacity and Community-Facility Linkages in Nepal

The Partnership for Maternal and Neonatal Health Project implemented by HealthRight International in two rural districts of Nepal tested an intensive intervention to strengthen community health management systems to increase the availability of high-quality facility-based maternal and newborn care services and linkages to them. The intervention included these strategies:

  • Health Facility Management Strengthening Program (HFMSP) with Health Facility Operation and Management Committees (HFOMCs)
  • A maternal and newborn care (MNC) quality improvement process with health workers in eight health facilities that involved self-assessments
  • Maternal and newborn near-miss and death review process
  • Provision of essential newborn care equipment to the five health posts and the district hospital to which they referred patients

The aggregated MNC quality assessment scores from the eight health facilities in the intervention exceeded the 80% target for all the nine tools, with a marked increase in average scores, especially on Tool 1: Infection prevention, Tool 2: Focused ANC, Tool 3: Complication during delivery, Tool 4: Normal delivery and immediate newborn care, Tool 7: Complication during labor and childbirth and Tool 8: Assessment of newborn with problem.

Source: HealthRight International 2013