Con el fin de identificar oportunidades y necesidades de apoyo a las redes municipales de salud para mejorar el Programa Nacional de Control de la Tuberculosis (PNCT) de Bolivia, el Proyecto Gestión y Calidad en Salud en asocio con el Proyecto de Garantía de la Calidad (Quality Assurance Project, QAP), decidieron realizar un diagnóstico rápido de la situación del PNCT en dieciséis municipios priorizados de los Departamentos de La Paz, Cochabamba y Santa Cruz. Los datos para el diagnóstico fueron recopilados entre noviembre 2006 y enero 2007. Los hallazgos sirvieron para desarrollar intervenciones de mejora que fueron implementados por medio de un colaborativo de mejoramiento iniciado en 2007 en los mismos municipios.

This report presents the results from of the Quality Assurance Project’s three Safe Motherhood Studies: competence of skilled birth attendants, the enabling environment for skilled attendance at birth, and the causes of the "third delay"—the delay in receiving medical attention after a woman arrives at a healthcare facility. The studies included five hospitals: a tertiary care referral hospital in the capital, two secondary care provincial hospitals, and two small district hospitals.

The present document reports on an operations research study conducted by the Quality Assurance Project (QAP) to examine the process of institutionalizing a Continuous Quality Improvement (CQI) process within the context of the reforms introduced by the Law for the Provision of Free Maternity Services and Child Care. The objectives of the study were: a) Describe and document the process, methods, and results of scaling-up and institutionalizing a quality assurance mechanism within the Free Maternity Program of the Ministry of Health of Ecuador; b) Explore associations between the degree of institutionalization achieved and the presence of reforms introduced by the Law, believed to be favorable to the QA institutionalization process; and c) Synthesize lessons learned that can be adapted and applied in other Latin American countries. The main research questions of the study were: a) Is it possible to achieve expansion of CQI through a decentralized intervention involving staff from provincial offices of the MOH (CQI facilitators), who replicate training sessions and locally support and monitor the work of quality improvement teams?; b) Which are the main factors that facilitate or constrain the application of the CQI model?; c) What is the model's cost?; d) What are the results in terms of the extent of CQI expansion and quality improvement of healthcare? (excerpt)

This course is based on the content of the conceptual framework for quality assurance and health sector reform that was developed by the Pan American Health Organization (PAHO) and the Quality Assurance Project (QAP). The framework is presented in the Latin America and the Caribbean Regional Health Sector Reform Initiative report, Maximizing Quality of Care in Health Sector Reform: The Role of Quality Assurance Strategies. The course does not include all of the content of the conceptual framework. By the end of this course, participants will be able to describe how to integrate health sector reform (HSR) and quality assurance (QA) strategies in quality-oriented health sector reform. (excerpt)

Trained clinical observers used a structured checklist at referral and district/regional hospitals in four developing countries to monitor care provided to 245 women during labor, delivery, and postpartum and their newborns during postpartum. The countries were Benin, Ecuador, Jamaica, and Rwanda. Observation periods were either continuous and lasted 72 hours or noncontinuous and lasted 12 hours over 4--6 days; all such periods included a weekend day and night. Observers marked the checklist to record the times when healthcare providers performed certain tasks and whether each had been done according to standard. Certain circumstances--such as a woman giving birth before arrival--required rigorous data cleaning. The quality of care for the different tasks is reported here by country, by hospital type, and overall. The frequency of labor monitoring was well below the rates recommended in all four countries, regardless of hospital type. Fetal heart rate (FHR) was monitored the most frequently at 1.3 times per hour, although its recommended rate in all countries is twice an hour. Other labor indicators recommended at twice per hour were checked less often: maternal pulse was taken 0.43 times per hour, contraction intervals 0.38 times per hour, and contraction duration 0.37 times per hour. The two indicators recommended at the rate of once every four hours (0.25 times per hour) were performed more frequently: maternal blood pressure at 0.63 times per hour and vaginal exam at 1.1 times per hour. On average, in 26% of the cases, no labor indicator was monitored at all. In the three study countries where partograph use is recommended, incorrect use was observed in more than half the case observations, varying substantially by country. Correct partograph use was associated with more frequent labor monitoring. (author's)

The Quality Assurance Project (QAP) investigated strategies for increasing efficiency in hospital laboratory services, an area of hospital operations that is frequently identified as high cost. The study developed measurement methodologies for seven separate sources of economic waste in hospital laboratories (unneeded tests, unclaimed tests, resource use inefficiency, staffing inefficiency, expired reagents, poor quality control, and inefficient procurement) and tested them in three public hospitals in Ecuador. The methodologies were intended to provide rapid assessments of the economic waste in each source and so relied on data from existing hospital records and relatively short turnaround surveys. Estimates of economic waste were made for each source by comparing actual measured costs to what the costs would have been if standards were met. The application found that the measurement methodologies were useable, in the sense that they could be applied and the requested data obtained. We found thateconomic waste from unneeded tests and staffing inefficiency may be very large. Findings on a sample of unneeded tests in six disease categories (acute diarrhea in children and adults, pneumonia in children and adults, appendicitis, cholecistitis) indicated that roughly half were unneeded and may represent economic waste. This result is based on clinical standards for lab tests developed through consensus by each hospital and may not apply to other disease categories. The economic waste of staffing inefficiency was estimated to range from 15% to 25% of the total laboratory budget across the three hospitals. However, these figures probably overstate the actual economic waste due to over-staffing because they do not account for staff time spent on indirect and other productive tasks. Economic waste from inefficient procurement of reagents and materials was estimated to be very high at one of the three hospitals due to lack of systematic competitive bidding. Additional refinement of the measurement methodologies is needed to obtain information that is valid and useful. This report identifies the areas that need to be strengthened in each methodology. Some examples: the need to develop clinical standards for lab tests was not originally envisioned, and the successful development of standards for six disease categories needs to be extended to other categories to ensure a representative selection that can be generalized to all test. Poor record keeping and erratic discard practices for unclaimed tests and expired reagents suggest that improved ongoing monitoring and reporting of these problems may be necessary to acquire valid data. Information on the cost of benefits and other payroll costs should be incorporated into the staffing inefficiency methodology, along with information on all productive tasks carried out by laboratory staff. These and other refinements would improve the validity of the methodologies. Finally the issue of double counting needs to be addressed as such information is incorporated into management decision making. (author's)

In an attempt to address high maternal mortality and morbidity in Latin America and the Caribbean, the United States Agency for International Development (USAID) began the Latin America and Caribbean Regional Initiative to Reduce Maternal Mortality (LAMM) in 1996. Recognizing that existing USAID-supported programs already address family planning, prenatal care, and clean delivery strategies to reduce maternal mortality, LAMM targets essential obstetric care at the first level of referral facilities. Bolivia, Ecuador, and Honduras were sites for the development and pilot testing of essential obstetric care (EOC) interventions. Under LAMM, the Quality Assurance Project (QAP) is responsible for supporting process redesign and quality improvement teams as they address weak components in the EOC system. QAP conducted a baseline assessment of the quality of care and compliance with EOC standards at the facility level in a selected area of each country in 1998. The QAP LAMM team developed a set of 21 indicators to measure quality of care and how each system was functioning. Data on the indicators were collected through the review of patient medical records and other facility records, structured observation of deliveries, and a questionnaire completed by healthcare professionals. The assessments indicate that adequate infrastructure to provide EOC exists in all three study areas. However, deficits were documented in the capacity of these facilities to deliver quality EOC services. Inadequate supplies and equipment, lack of trained personnel, and failure to comply with quality standards all limit the functional access to EOC. The assessments also suggest that low utilization of the study facilities is an important barrier to the delivery of EOC in all three countries. Over a third of the staff surveyed reported never having been trained in the management of obstetrical emergencies. With respect to the performance of clinical EOC tasks, the assessments found that time intervals between recordings of fetal heart rate failed to meet international standards. Asepsis was routinely practiced during delivery in all three countries, while the administration of hemoglobin tests to patients whose admitting diagnosis suggested the possibility of hemorrhage varied widely among the three countries. The assessments also examined whether basic tasks were recorded in patients' medical records, and many tasks appeared unrecorded. The assessment results suggest that a variety of interventions will be required to increase awareness of and compliance with performance standards. Such interventions could include effectively disseminating and communicating standards, in-service training, job aids, increased supervision and monitoring, and assuring availability of supplies and equipment through process redesign and quality improvement. The LAMM initiative contemplates repeating assessments in 2001 to evaluate the effectiveness of its efforts. The adequacy of the 21 indicators to reliably measure the initiative's achievements should be reviewed, and efforts should be made to better standardize data collection instruments and sampling methods. Some of the original indicators may be hard to interpret as gauges of progress, and there may be other indicators that should be introduced. A new set of nine indicators, including five of the original ones, has been introduced by LAMM for routine quality monitoring. These indicators should be considered for future facility assessments. (excerpt)

Significant improvements to healthcare services are possible with an understanding of clients' perspectives, but those perspectives often go unexpressed or are expressed without detail through verbal complaints or complaints dropped in suggestion boxes. Exit interviews and focus groups are among several methods for collecting detailed information from clients, but little research has been done to test those methods in developing countries. The Quality Assurance (QA) Project investigated six methods for collecting client feedback at two healthcare clinics in Chiclayo, Peru, from September 1998 to April 1999. This report summarizes the results of that study, presenting both a description of the information collected and a comparison of six data collection methods. Information is also presented on how managers involved in the study used the data to improve clinic services. The report concludes with lessons learned and guidance on how to improve client feedback systems. The study site was the Max Salud Institute for High Quality Health Care, started in 1994 with funding from the U.S. Agency for International Development (USAID). Max Salud is a private, nonprofit organization whose clients chose between using its services and nearby public clinics. At the time of the study, Max Salud provided a broad range of health services to 20,000 low- to middle-income people through two clinics supported by a central management unit. Max Salud wanted the client feedback system in order to collect clients' perspectives of services and to convey those perspectives in summary fashion to its quality committees, which would then use the information for quality improvement. Exit interviews, follow-up visits, focus group discussions, interviews with discontinued clients, suggestion boxes, and community meetings were the intended data collection methods, although the community meetings, ongoing at the start of the study, proved to have been structured in such a way that elicited little client feedback. The data from the client feedback system indicated high client satisfaction with the quality of services, especially the friendly personnel, clean and pleasant settings, and prompt service. Quality improvements resulting from the study included improving the response time to client complaints, sensitizing clinic personnel to clients' concerns, and reducing waiting times. The validity, utility, and feasibility/cost of the different methods varied considerably. For example, exit interviews were very feasible and provided quantitative data valued by quality committees, but their structured format limited clients' expressions of dissatisfaction. Focus groups yielded rich, detailed information, but were expensive and time consuming. (author's)