This TRM reviews the importance of quality in health care and describes how quality improvement approaches can be adapted to the needs of low- and middle-income countries (LMIC) to improve health care for high-burden conditions. It describes the quality gap that persists worldwide between the care we want and the care we have, and it highlights the fact that the ultimate measure of quality of care is the health outcome that the care produces. The TRM reviews key principles of quality improvement and describes approaches commonly used to improve care, drawing on a large body of experience in applying improvement methods to facility- and community-based health care. Several examples of how improvement methods were applied in specific community health projects are highlighted in text boxes throughout the paper.
THE QUALITY GAP
Poor quality of health care is widely recognized as a major barrier to achieving optimal health outcomes and economic development, especially in LMIC. Despite an abundance of evidence-based guidelines, health care services worldwide often fail to deliver safe, compassionate care to patients when and where they need it. Studies of care delivery in LMIC demonstrate widespread deficiencies in the care provided at all levels of the health system. While there is broad global consensus on what should be done to deliver quality health care, many simple, high-impact interventions capable of saving lives and alleviating suffering are not reaching the people who most need them. Much of this implementation “know-do” gap is related to weak health systems and processes of care delivery. As World Health Organization (WHO) Director General Margaret Chan aptly noted, “The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and at an adequate scale.”
Many factors contribute to poor quality of care and weak health systems:
- Governance and policy: Inconsistent or ineffective national policies, standards, leadership and accountability mechanisms
- Financing: Lack of financing for priority services, workforce, and essential inputs
- Essential commodities: Lack of functional supplies at the point of service delivery
- Health worker competence: Weak knowledge and skills and poor maintenance of provider competence after training
- Organization of care processes: Poor organization of care processes and poor adherence to evidence-based standards
- Health information systems: Lack of routine collection and analysis of quality of care data to improve services.
In community and primary health care services, common contributors to poor quality of care include lack of clear guidelines on what community health workers are supposed to do; lack of access to life-saving commodities; overburdened health workers with too many tasks and too many households to cover; and weak linkages between community health systems and the formal health system. Indeed, community and formal health systems often co-exist in isolation, despite the fact that clients may move back and forth between the two systems. The lack of linkages between community and formal health systems often results in poor quality of care, including lack of coordination and continuity of care for clients. Despite the challenges, ample evidence from many LMIC indicate that it is possible to achieve high-quality health care, even with limited resources. Recognition is growing of the need for what a recent editorial in The Lancet termed a “third revolution in global health—a revolution in the quality of care” (Horton 2014).
QUALITY IS A FUNCTION OF THE HEALTH SYSTEM
If we understand health care as work produced by systems, then any health system—community or facility based—is only as strong as the outcomes it produces.
Avedis Donabedian’s conceptual model of the health system shown at the right illustrates how physical and organizational settings and resources (structures) are transformed by processes of care delivery and supportive functions into services for clients that determine client health outcomes (Donabedian 1980).
Many public health efforts focus on key structures or inputs (e.g., trained health workers, commodities, guidelines) and pay relatively less attention to how these inputs are translated into processes of care for clients.
One reason that health care in so many countries has safety and quality problems is because poorly organized care systems lead the workforce to fail, regardless of how hard they work. Having competent workers, needed drugs, and technology available are necessary but not sufficient to achieve appropriate care; the process of organizing care is critical to ensure that such inputs are appropriately used to attain the desired outcomes.
The field of complexity science offers insights about how health systems behave as complex adaptive systems, where a large number of independent interactions interconnect in sometimes unpredictable and continually changing ways (Plsek & Greenhalgh 2000). Health care involves interactions among many different actors, including handoffs, coordination across levels and specialties, and provider and client attitudes and behavior. This complexity is equally true of health care in resource-limited settings as it is in high-income ones.
WHAT DO WE MEAN BY QUALITY IN HEALTH CARE?
There is no single definition of quality in health care. The following definitions have many elements in common:
- “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (The Institute of Medicine, USA)
- “Quality care is doing the right thing at the right time, all the points of service along the continuum of care. High quality care is a function of the system's ability to produce care that will address the client's needs in an effective, responsive and respectful manner.” (David Nicholas, Director, USAID-funded Quality Assurance Project)
- “The proper performance (according to standards) of interventions that are known to be safe, that are affordable by the society in question, and that have the ability to produce an impact on mortality, morbidity, disability and malnutrition.” (Milton Roehmer and Carlos Montoya-Aguilar, WHO)
In 2001, the Institute of Medicine of the United States published a seminal report, Crossing the Quality Chasm, that highlighted the chasm between the “the health care we could have and the care that we have” in the United States (Institute of Medicine, 2001). The report emphasized that “problems come from poor systems—not bad people” and that efforts to improve care must be anchored in a consideration of how systems of care operate in real-life complex delivery systems.
To address the problem of poor systems, the Institute of Medicine defined six aims for what constitutes quality and value in health care:
- Safety: Health care should avoid injury/harm to patients and clients.
- Effectiveness: Services should be based on scientific evidence.
- People-centered: Care should be respectful of and responsive to individual patient or client preferences, needs, and values.
- Timeliness: Care delivery should minimize client waits and avoid harmful delays.
- Efficiency: Care should maximize outputs for given inputs.
- Equity: Access to care and care quality should not vary due to client gender, ethnicity, geographic location, socioeconomic status, or other personal characteristics.
These aims are equally useful for understanding health care quality gaps in LMIC. Together they provide a useful gauge for assessing whether care, be it at the facility or community level, provides quality and value: Is it safe? Is it effective? Is it people-centered? Is it timely? Is it efficient? Is it equitable?
The definition of quality also depends on the perspective of who is defining it. The Institute of Medicine aims to address multiple perspectives—those of managers, providers, clients, and the broader community. With the Institute’s acknowledgement that different actors may have differing points of view about what constitutes quality indicates the need to engage all these different perspectives in quality improvement efforts.
Save the Children’s Partnership Defined Quality (PDQ) approach describes a four-step process for involving communities in efforts to improve the quality and availability of health services (Lovitch et al. 2003). Providers and community members work together in a series of structured meetings to identify and address priority problems (Save the Children 2004). PDQ posits that quality may be defined from different perspectives (those of clients, those of providers) and that providers and clients can work together as allies to address problems and develop a common vision for quality care.
The adaptation of delivery services to address client cultural preferences is an example of client-centered obstetric care. In Ecuador, health workers, traditional birth attendants, community leaders, and pregnant women came together to define what would be considered high quality, culturally acceptable delivery care, taking into account both evidence-based clinical practices and cultural preferences, such as delivery position and presence of birth companions during delivery. The cultural adaptation intervention showed that rates of institutional delivery increased when health facilities addressed these cultural preferences (Hermida et al. 2008).
Text box: Partnership Defined Quality
Save the Children developed Partnership Defined Quality (PDQ) as a systematic method to bring health care providers and community members together to identify and address priority problems. The method consists of four steps to ensure that the quality improvement effort is truly a joint activity:
- Build support to secure buy-in from all stakeholders.
- Explore quality by using separate analyses with providers and community members, including non-users, to identify perceptions about quality.
- Conduct a bridging-the-gap workshop for representatives from both groups to share perceptions and develop a common vision for quality care.
- Establish a quality improvement team to represent both groups.