Quality of care in health systems

ALISON MORGAN: Hi. My name is Alison Morgan. There has been a renewed focus on the quality within health care systems, driven in part by the realisation that at the end of the Millennium Development Goal era, high coverage of known interventions didn’t always translate to better outcomes. Countries that have had similar coverage of skilled birth attendants, for example, had vastly different maternal mortality ratios. Simply having birth attendants in place doesn’t mean that the right care at the right time is always provided. So at this point in the course, we want you to have an overview of both the definitions and the frameworks that different agencies have used, including the most recent 2015 WHO quality care framework for maternal health.

But before we start, I want to remind you of some of the frameworks for health systems that we’ve looked at throughout this course. In the WHO building blocks framework, there is an implicit understanding that if you get the human resources, financing, and supplies working well, then quality will follow. And I’d like to consider whether this is the case in your setting. Can you assure quality will follow just by having the so-called “four Ses” in place– Staff, Stock, Stuff, and Skills? What do you think? In the World Bank model, the so-called “control knobs” approach, there is a stronger link with quality, recognising that behaviour and health work and motivation and how services are organised all change quality.

But the mechanism is still not really explicit. And quality can be understood in many different ways. Look at these expressions, where quality is equated with comprehensive care, for example. “Every test was performed.” Or comfort– “I had a private room. And the food was fantastic!”

Others simply equate quality with survival: “Well, I survived the childbirth. And my baby survived. So I must have had good, quality care.” The definitions vary. And this has implications for how we measure it, how we monitor it, and how we can improve it. In the year 2000, the Institute of Medicine in the USA published their definition, which has now been widely adopted by WHO and others. The authors nominate six domains that together define quality of care. It must be safe, by which we mean that we’re not doing any harm. The treatment must be based on sound clinical evidence. And it should be patient centred, which is a term that many people mention.

But it needs to be understood in the particular context because people’s needs vary. But it’s around giving patients a good experience of care. From a systems point of view, quality needs to be equitable, which is often used interchangeably with accessibility. Because if it’s an equitable service, everyone gets access to it. It also needs to be timely. So for example, we need to ensure that vaccines are given according to the correct schedules and before a child is too old for the vaccine to be of benefit. And then the last domain is efficiency, using resources in a way that ensures that costs are minimised and waste is minimised.

Now, once we have an agreed definition, it makes sense to consider how we approach ensuring our health systems are providing quality of care. And there are a number of different frameworks. I want to take you briefly through them because I think they help us understand how we can think about quality of care frameworks within the whole health system. And then we’ll examine in more detail the WHO framework for maternal health that I mentioned earlier. Joanna Raven from the Liverpool School of Tropical Medicine and Hygiene published a review of quality care frameworks in 2012. And I want to go through the first three of these frameworks she describes. The first framework is a perspectives framework.

Within this framework is a recognition that what a patient calls quality, what a health planner and how they perceive or define quality, and how the health workers define quality may all vary substantially. Many things will be very similar. But each will also bring their own perspective. And the implication of this framework is that you can’t just assume that because you’ve interviewed a whole lot of health workers you understand the quality issues. Or just because you’ve talked to, say, women you understand the quality of their issues from their perspective. The point of this framework is that you need all of these perspectives in order to get a good understanding of quality.

The second way of conceiving quality is through what Joanna Raven describes as a characteristics framework. Within this framework, there is a list of required components divided into both the provision and the experience of care. And the assumption is, if you have all of these in place, then quality is assumed to also take place. And finally, the third framework that Raven describes in more detail is a systems framework. Many of you may have heard of Donabedian, who did the earliest work in the mid-1960s around how to define a health system. And he defined it in terms of the structure, of the processes, and of the outcomes.

Now, later on we’ll have a reading where you see how WHO has incorporated all of these frameworks into their 2015 quality of care framework for maternal health, capturing the perspectives, the provision and experience of care, and the Donabedian structure, process, and outcomes distinctions. But as you would have heard by now, within health systems, we’re talking about what we call a “wicked problem,” or complex systems where the agency or any changes affects changes along the way. So we also need to recognise that we’ve got a complex adaptive system happening when we think about quality of care. Now, we’ve touched on this earlier.

But it’s worth being reminded about the difference between the traditional approach of having a whole lot of inputs with a whole lot of anticipated outputs versus what actually is happening in complex adaptive systems. Within these complex systems, it’s leadership that is important, not just having a whole lot of management guidelines. It’s having enablers and incentives rather than having a very strict command and control attitude to staff. You need to be agile and be responsive to the situation, which means you need to understand the context and to be monitoring it and to recognise that health workers themselves are agents that will respond differently to different circumstances.

However, regardless of the framework you choose in assessing quality, you’ll eventually be doing a very standard cycle of quality improvement, where you define what standard you want, where you measure what current standard you’ve got, where you look at the gaps, and then you report against that and make an action plan that might really address those gaps and improve the quality. And also across all of these frameworks, there is the need to have a means of measuring. Not surprisingly, there are many different tools for measuring quality of care.

At an individual facility level, often observation is one of the best measures of clinical practice and clinical quality, although people tend to behave differently when they’re being observed than in their routine practice. Interviews, clinical audits, or the clinical records of a particular condition are reviewed also are effective tools for assessing quality at that facility level. For national assessments, facility audits, particularly through internationally validated surveys such as the SPA or the SARA, can be very helpful to assess the quality of infrastructure, the supplies, the drugs, and the systems within the facilities.

And then, as should be familiar, the routine health information systems, the health management information systems, or how well DHIS2 is working– all these tools can contribute to our understanding and measuring of quality. In summary, our take-home message is we want you to recognise that because the focus has been on coverage to date, quality has often been overlooked. The challenge of quality care is that we haven’t had good standard definitions. And we haven’t had standard measures.