In 2007, PEPFAR, through the United States Agency for International Development (USAID), created the Care that Counts initiative with support from the USAID Health Care Improvement Project (HCI) to support countries and implementing partners in improving the quality of programming for vulnerable children. Over the years, many lessons have been learned about the process of improving quality of care for vulnerable children, and these lessons have been compiled in the interactive USAID Care that Counts e-Learning Course for Quality Improvement in Programs for Vulnerable Children. This short flyer describes the details of the e-learning course, which can be accessed here: http://www.hciproject.org/elearning/care-that-counts.
By the end of the e-learning course, learners will be able to describe the principles of quality improvement, explain the road map for enhancing programs for vulnerable children through a quality improvement approach, begin to organize for quality improvement in their own work using the lessons learned from the Care that Counts initiative, and access additional resources to assist them in integrating QI into their work.
Modern quality improvement methods benefit from the value of teamwork, supportive coaching of teams, process analysis of services, and the use of data to monitor results and decision making. Based on these values, the collaborative improvement approach has taken these principals further by adding the features of multiple quality improvement teams working on the same objective, shared learning, friendly competition, and rapid scale-up of improvement. Collaborative improvement recognizes that team members who are providing a certain service bring valuable insights regarding the process of service delivery, and hence they are more likely to come up with innovative ideas to improve the process and the service outcome. When applied to the health field, the approach empowers health staff themselves to identify performance gaps, suggest and test ideas to improve results in a specific period of time, and share their experience and learn from others.
Objective. To develop a framework to support the institutionalization of quality assurance (QA). Design. The framework for institutionalizing QA consists of a model of eight essential elements and a ‘roadmap’ for the process of institutionalization. The essential elements are the building blocks required for implementing and sustaining quality assurance activities. Core QA activities include defining, measuring and improving quality. The essential elements are grouped under three categories: the internal enabling environment (internal to the organization or system), organizing for quality, and support functions. The enabling environment contains the essential elements of leadership, policy, core values, and resources. Organizing for quality includes the structure for implementing QA. Three essential elements are primarily support functions: capacity building, communication and information, and rewarding quality. The model can be applied at the level of an organization or a system. The paper also describes the process of institutionalizing QA, starting from a state of pre-awareness, passing through four phases (awareness, experiential, expansion, and consolidation), and culminating in a state of maturity. The process is not linear; an organization may regress, vacillate between phases, or even remain stagnant. Some phases (e.g. awareness and experiential) may occur simultaneously. Conclusion. The framework has been introduced in nearly a dozen countries in Latin America and Africa. The conceptual model has been used to support strategic planning and directing Ministry of Health work plans, and also as a resource for determining the elements necessary to strengthen and sustain QA. The next step will be the development and evaluation of an assessment tool to monitor developmental progress in the institutionalization of QA. Keywords: framework for quality assurance, institutionalization framework, leadership for quality, organizing for quality, quality assurance, sustainability of quality assurance
A standard is a statement of what is expected. Many types of standards exist in health care. Determining what type of standard is needed can be confusing, therefore, a taxonomy (or classification) of health system standards has been developed. A taxonomy is a classification system for organizing and labeling terms. The following taxonomy of health system standards will assist in the understanding and development of standards in healthcare. The intent is to propose a systematic way of organizing standards as well as provide consistent terminology. This information will help persons responsible for healthcare to systematically develop standards to meet healthcare needs in their respective communities. (excerpt)
A revolution is taking place in the field of healthcare. The concept of "quality of care," a major concern in the '90s, is now reverberating into the new millennium, speeded by the advent of healthcare reform in many countries. Providing quality healthcare within the constraints of available resources is a challenging undertaking. Nonetheless, even in an environment with limited resources, methods are available to regularly monitor the quality of care by collecting and analyzing a core set of health indicators, and thereby laying the groundwork for improvement. This guide provides a systematic approach to implementing quality monitoring in a hospital. Quality monitoring is only one part of a comprehensive approach to improving the quality of healthcare. Some of the other components include: providing feedback to healthcare workers, training and supporting staff to undertake improvements leading to quality care, and designing solutions for closing identified quality gaps. The focus of this guide ison measuring and analyzing processes rather than individuals. Seeking a culprit for poor outcomes is not the objective of monitoring. Too often individuals are held accountable for poorly designed systems and processes. In order to develop trust and involve staff in quality monitoring, the emphasis must be placed on the improvement of processes. The involvement of healthcare managers and providers in designing the monitoring process and assuming ownership are critical to establishing, implementing, and using an effective system that can lead to improved healthcare. (author's)
There remains a critical lack of skilled health professionals in the developing world. Unfortunately, leaving home, family, and work to attend training courses in urban centers large enough to have training facilities or universities is not a viable option for many potential and currently practicing health professionals. As a response, the implementation of distance education programs to widen access to such students has grown steadily in the last two decades. From the University of South Africa to Indira Ghandi Open University (IGNOU) in India, there are now a plethora of preservice and post-graduate programs in health and medicine around the world. The QA Project is studying and implementing cost-effective intervention in international healthcare that improves the quality of healthcare delivery and overall health outcomes. The QA Project believes that education at a distance represents a potentially cost-effective approach for training preservice and inservice health workers in a variety of health topics. A review of the current body of quantitative and qualitative research on the implementation, costs, and effectiveness of distance education for healthcare providers appears on the following pages. Though largely undocumented, an attempt was made to include studies of the use of distance education in developing countries. (excerpt)
Self-assessment could be particularly valuable in developing country healthcare settings where individual service providers often work without a supervisor or colleague to guide their performance. The QA Project has an interest in self-assessment and its impact on performance because of the intricate link between performance and quality. This paper examines the issues relating to self-assessment, such as the different types of self-assessment, its uses, and its validity. It also reviews the literature (largely from developed countries) that informs our knowledge of self-assessment. The paper makes recommendations for future research and concludes that while much remains to be done to assure that self-assessment has the impact it promises, it may also be less costly and easier to implement than alternatives. (author's)
This document explores the cost issues associated with implementing quality improvement initiatives in developing country health settings and determines the economic benefits of management systems for improving quality. It consists of a series of presentations drawn from applied experiences and operational research done in the area. Such presentations address certain topics, which include Application of Activity-Based Costing to Manage the Cost of Quality in Health Services in Peru, Cost and Quality of Care: the Relationships Between Cost and Compliance with Sick Child Care Standards in Niger, and Evaluating the Economic Impact of a National Quality Assurance Program in Niger. The presentations emphasize the symbiotic links between cost management and quality management. Potential issues and solutions in implementing cost and benefit analyses of Quality Assurance in developing countries are also addressed.
The Quality Assurance Project (QAP), funded by the US Agency for International Development, provides comprehensive, technical expertise in the design, management, and implementation of quality assurance programs in developing countries. As such, a monograph was created which represents an update on quality improvement methodology for health care delivery. Divided into nine sections, the monograph outlines the principles and frameworks underlying quality improvement in health care. A history of the QAP is presented in Section 1. Section 2 describes the spectrum that covers the range of quality improvement methods and defines four points along this spectrum, namely: individual problem solving, rapid team problem solving, systematic team problem solving, and process improvement. Sections 3, 4, 5, 6, 7, and 8 detail the methodology for improvement for each four approaches, with accompanying illustrations. Finally, Section 9 describes the tools used in quality improvement that include data collection, process description, and data analysis tools.
This document is the first report of the research component of the Quality Assurance Project (QAP), which helps developing countries design and implement effective strategies for improving the quality of health care. This report describes how the QAP introduces quality assurance methods into health care delivery systems in developing countries. The first part explains how the quality of health care has been assessed and improved in developing countries. Part 2 discusses the feasibility and rationale for using quality assurance methods to define clinical guidelines and standard operating procedures, assess performance against performance standards, and improve program performance and effectiveness. The third part offers definitions of quality and analyzes the following dimensions of quality: technical competence, access to services, effectiveness, interpersonal relations, efficiency, continuity, safety, and amenities. Part 4 reviews the definition and basic tenets of quality assurance. The fifth part outlines the following steps in the quality assurance process: planning, setting standards and specifications, communicating guidelines and standards, monitoring, identifying problems and selecting opportunities for improvement, defining the problem, choosing a team, analyzing the problem to identify its root cause, developing solutions and actions for quality improvement, and implementing and evaluating efforts. The report ends with a consideration of the challenges of creating a quality assurance program.
For the last decade, stand-alone training offered on computers has been used extensively in the US for training medical students and health providers. In many instances, health providers have demonstrated improved knowledge scores upon completing computer-based tutorials, and when compared with traditional facilitator-led training, computer-based training has yielded equal and sometimes higher test scores. However, there remain serious questions on the long-term performance of providers after using computer-based training and the cost issues associated with its development and implementation. In this paper, the Quality Assurance Project (QAP) reviews the current body of published and nonpublished research on the effectiveness of computer-based training in health care. Special focus is made on its implementation in developing country settings and on areas of research that QAP feels should be addressed.
This monograph is part of the Quality Assurance Methodology Refinement Series published by the Quality Assurance Project. Like the other monographs in the series, its purpose is to help those promoting Quality Assurance in health care and other services to achieve lasting impacts. The monograph focuses on how to design, develop, and deliver efficient and cost-effective training. The monograph presents practical guidelines for creating successful learning experiences and provides step-by-step assistance in key training elements, from assessing the need for training to evaluating course preparation and outcomes in the workplace. (excerpt)
This monograph presents a conceptual framework to help healthcare systems and organizations analyze, plan, build, and sustain efforts to produce quality healthcare. The framework synthesizes more than ten years of QA Project experience assisting in the design and implementation of QA activities and programs in over 25 countries. That experience has shown that the key institutionalization question is often not so much a technical one--how to "do" QA activities--but rather, how to establish a culture of quality within the organization and make QA an integral, sustainable part of the health system. As with any kind of organizational change, the road to institutionalizing QA can be long and complex. This monograph was written to provide practical information to Ministries of Health and other health organizations in their quest for sustainable quality of care. It both describes the components necessary to inculcate a culture of quality and provides practical information on how to facilitate the process necessary to reach this goal. A framework of eight essential elements and a phased process for institutionalization of QA outline the critical aspects and a road map for creating a lasting program to improve the quality of healthcare. The institutionalization framework draws heavily on management literature and organizational change models, as well as QA program experiences in diverse countries. (excerpt)
This paper describes the use of manual job aids as an innovative intervention to help improve the performance of health care providers. The Quality Assurance Project has focused its attention to this particular intervention because of its suitability for use in the manual and noncomputerized health care settings that are common in the developing world. This concept represents a potentially cost-effective tool to improve the overall process of health care delivery, especially by facilitating compliance with health care standards. Moreover, this paper reviews literature that summarizes the state of quantitative and qualitative research on different health care provider job aids formats and the impact of these job aids on provider performance. It was found that job aids address some of the causes of the provider noncompliance such as provider forgetfulness, lack of time, and certain organizational barriers. Lastly, health planners and managers working in the developing countries have indicated that manual job aids are ideal for preventive health tasks, inexpensive to produce, and often reduce or replace the time and expense needed for conducting off-site training.
Performance according to standards is the cornerstone of quality assurance in healthcare and the end result inspiring many quality assurance activities. However, even when locally appropriate, evidence-based standards are available, many health workers do not routinely follow them. Motivating and enabling health workers to perform in accordance with standards is deterred by many factors-behavioral, social, and organizational-as well as the nature of healthcare activities and their setting. This paper reviews several theoretical perspectives to increase understanding of the key determinants of health worker performance, including theories of behavior change, diffusion of innovation, health education, and social influence. The main types of interventions that have been used to encourage health workers to perform in accordance with standards are described, and evidence from empirical research for their effectiveness is summarized. (excerpt)