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• W2024954730 abstract "Current global health strategies for maternal, newborn and child health (MNCH) are focused on a limited number of low-cost, high-impact interventions. Specific interventions, such as the active management of the third stage of labour and protocols for the integrated case management of childhood illnesses, are the product of scientific research. In recent years, such basic interventions have been summarised in written clinical guidelines that describe the steps that the provider should follow in assessing and treating a given health problem. In some technical areas, the design of these guidelines may present challenges, but this discussion will focus on applying the many high-quality guidelines that are currently available. The efficacy of these basic MNCH interventions is well established. But their actual effectiveness depends on how they are implemented in large-scale programmes, and the coverage attained by these programmes. Performance measures based on the health-related Millennium Development Goals provide one indication of how far implementation has lagged in low and middle-income countries (LMICs), especially in Africa. In addition, direct evaluations commonly show that providers fall short of the care described in clinical guidelines. The largest published review of how closely clinicians follow clinical guidelines in MNCH and other basic services included 1338 facilities in 12 LMICs.1 On average, providers in these facilities carried out only 38% of the tasks specified in the guidelines. Evidence-based clinical guidelines have been widely adopted in LMIC health systems. However, these findings suggest that health systems have not yet developed effective support mechanisms to enable providers to implement the guidelines reliably. This is a quality of care problem. We will examine the practical implications of the concept of quality of care within MNCH programmes, using Donabedian's systems model.2 We will outline the potential of available methods to improve the quality of these services in LMICs, and discuss a learning agenda to advance the state-of-the-art for such improvement efforts. Definitions of quality often describe health care that is effective, efficient, accessible, patient-centred, equitable and safe.3 However, for practical efforts to improve care, quality is defined by one or more quantitative indicators that are used to measure performance in a narrowly defined component of health care. We deal with quality as a measurable attribute of health services. If, for example, antenatal care includes counselling on danger signs, we need to develop ways to measure improvement in this element of care. In his classical systems model, Donabedian2 framed health care in terms of the inputs or resources needed to provide care, such as trained staff, drugs and clinical guidelines. With these inputs, the health system carries out a series of processes or activities to provide care. A major category of healthcare processes is the degree to which providers follow clinical guidelines, but health care also requires nonclinical and administrative processes, such as managing records and human resources. In this model, a series of processes may lead to an outcome which, in turn, becomes an input to another series of processes. For example, the processes involved in filing and retrieving medical records might lead to the outcome that the clinician has timely access to a patient's record, and this outcome becomes an input to the processes involved in caring for the patient. Healthcare processes eventually produce outcomes that lead to health impacts. Hence, efforts to improve the health impact of MNCH services may need to address processes that seem far removed from clinical care. The general concept of quality could be applied to healthcare inputs, processes or outcomes. However, efforts to improve quality in high-income countries have been largely focused on healthcare processes.4 In LMICs, inputs are a more prominent issue because critical resources, such as magnesium sulphate and sterile gloves, are commonly unavailable. Donors are rightly focused on providing needed resources, but we will focus on the largely overlooked issue of improving healthcare processes, an area where external resources are not assumed. Established quality improvement (QI) interventions are primarily directed toward processes, and ‘process improvement’ is frequently used in place of ‘quality improvement’. In global health, this focus on process improvement reveals a large number of healthcare processes that are virtually unstudied and often poorly understood even by programme managers. This discussion will focus on improving the implementation of MNCH healthcare processes, including more closely following clinical guidelines. But we will also address the nonclinical, administrative processes that support clinical care. A number of methodologies have been developed with the objective of improving healthcare processes in MNCH. Clinical training is a necessary component for introducing new MNCH interventions, but it is also the most widely used strategy for improving MNCH services. Training is usually complemented by supervision of the providers. Recent reviews find that these approaches have had a surprisingly limited impact on provider behaviour.5, 6 A range of specific interventions aimed at improving care processes includes audit and feedback, job aids and accreditation of facilities. These approaches have also shown limited impact on care processes in reviews.7 Performance-based incentives have been widely studied recently, but little of this work is directed toward measures of quality. Further research may result in greater impact for some or all of these approaches, and new methodologies may also emerge. For example, recent improvements in the design of checklists may facilitate learning from the processes used by high performers (benchmarking). Developments in information technology also present new opportunities for communicating directly with patients about their opinions about health care and their role in this care. For the present, the leading process improvement approach in both high-income countries and LMICs is based on organising providers to conduct tests of changes in care processes. Changes that result in improvement can then be adopted on a large scale. This approach is based on methods developed in industry and applied to health care in high-income countries in the 1990s. Applications in LMICs soon followed. The tests-of-change approach is now supported by the largest evidence base of any well-defined process improvement approach, including the only multi-country evaluation published to date.1 A variety of labels have been used for this approach, including quality management and continuous quality improvement (CQI). In a major methodological advance, the Institute for Healthcare Improvement modified the organisation of CQI in the late 1990s.8 In place of individual teams of providers developing tests of change independently, the Institute for Healthcare Improvement organised dozens of teams in a collaborative effort to improve a selected area of health care. By systematically sharing the experiences of the teams, these collaboratives generally produced measurable improvements in care more rapidly than conventional CQI. Applications in LMICs produced similar results, including the multi-country evaluation cited previously.1 The shared learning approach used in collaborations also showed evidence of higher levels of provider motivation for improvement work, compared with traditional CQI.9 From a management perspective, there is little room for doubt that MNCH programmes need the capacity to examine and improve the processes they use to implement these services. However, a number of authorities have observed that organised process improvement efforts differ from scientific research, such as drug trials,10 and do not have predictable outcomes. Current improvement methodologies are complex social interventions involving a large number of actors, multiple variables and different contexts. One such intervention may differ in important ways from another with the same label. Hence, the results of a given process improvement activity cannot be predicted with confidence. Further, improvement activities are carried out by regular providers, not trained researchers. These issues are partially addressed by monitoring quality indicators over time, and displaying data in time-series charts. These ‘run charts’ are generally intuitive for managers and providers, and are supported by well-developed statistics.11 This could be considered ‘evidence-based management’: process improvement does not generate generalisable knowledge, but every improvement is based on its own tests of change. While providers in LMICs cannot be expected to duplicate formal research methodologies, they do have detailed knowledge of the care processes that they seek to improve. Further, providers are potentially available for process improvement in large numbers, in contrast to the scarcity of trained health service researchers. In view of the large number of unexamined healthcare processes involved in MNCH services, traditional research cannot replace a process improvement strategy. However, in view of our limited understanding of adapting process improvement to the needs of LMICs, research and evaluation are needed to complement these efforts. Recent experience in process improvement suggests a number of specific issues where research and evaluation are needed: Evidence-based clinical guidelines have provided us with important new insights into how high-impact MNCH services should be delivered. Evaluations consistently show that large-scale programmes fall short of these guidelines, despite traditional investments in training, supervision and technical assistance. While relatively few studies have directly examined the health impact of this level of performance in MNCH services, those studies confirm our expectations: Care that is reliably based on science produces better outcomes. The field of healthcare quality improvement provides a promising technology for addressing these deficiencies in clinical care, and the wide range of administrative processes that support the clinician. A more systematic approach to knowledge sharing—within and across MNCH programmes—promises to make process improvement increasingly efficient. This field also stands to benefit from expanded investments in research and evaluation focused on process improvement. The authors declare that they have no competing interests. JRH developed the first draft and carried out final editing. DA provided additional maternal health concepts and text, and edited the first draft. TAJ provided additional quality and child health concepts and text, and edited the first draft. This commentary does not address trials involving human or animal subjects or medical records. The paper deals with management and policy issues only, and does not require ethical review. No funding was provided for the preparation of this paper. Opinions expressed in this paper are those of the authors and do not represent the policies of the US Agency for International Development." @default.
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• W2024954730 title "Better care for every patient, every time: improving quality in low health systems" @default.
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