RIHFW Kashmir
Workshop on Quality Assurance in Health Care
Our country, like many developing regions, has made considerable efforts to improve access to health services. However, because of population increase, public health resources have got so stretched that the quality of services has declined markedly over the last few decades. Policy makers have realized that health services of inferior quality do not promote equity or maximize health gains. As a result, the public is becoming attracted more to private providers than to public health clinics and hospitals. For many reasons, such as low staff morale and reduced income, this has led to further decline in the quality and efficiency of public sector health services. It remains a challenge to find innovative approaches that improve the quality of health service delivery.
Quality Assurance (QA) is taken as an approach that health managers should consider in their attempts to systematically monitor and improve service delivery. Experiences from Quality Assurance programmes in different countries of the world including India, Ghana, Honduras, Costa Rica and Panama have provided valuable insights to the planners and policy-makers. Although principles, aims and objectives of quality assurance in health care remain the same for all, there can not be a uniform system suitable in different circumstances and no answers could apply equally to all situations. Therefore, each country, each region and each system needs to devise their own tailor-made strategies and approaches.
By definition. Quality assurance (QA) in health care is a planned and systematic approach to monitoring, assessing and improving the quality of health services on a continuous basis within the existing resources. It comes in many guises, and may be known by different names, however, all Quality Assurance systems should encompass three perspectives on quality:
- Clinical standards
- Performance management
- Client satisfaction
Quality standards which are set should be of specific nature and practicable. However, while specific objectives for policy statements may be set at the central level, implementation plans are best left to service-providers at the local level. Quality assurance is a continuous process; a continuum from central level to grass-root levels.
There may exist a model Quality Assurance programme, but improving quality of services demands a response from the service providers themselves. This is unlikely to happen with the top-down imposition of a bolt-on system for quality improvement. Instead a bottom-to-top approach may be a more suitable answer.
QA can either be introduced on a small scale at the district or local level, or in a big way as a national or regional programme. QA systems developed by facility-based staff are more likely to respond to local priorities and are far more likely to bring about the kind of quality improvements that service users themselves will appreciate.
Implementing QA systems is as much a 'people' issue as a 'technical' one. Providers implementing QA should guard against over-ambition. They should not try to set right everything in one go. They may instead start by focusing on a single issue, then, as a quality culture develops in the health service, add additional elements to the QA programme. Districts should be encouraged to develop their own QA initiatives that should be part of the annual work plan with their own budgets. It should be remembered that ownership by local service providers remains the secret to success in turning policy on quality of care into practice. And, for long-term sustainability, QA must be integrated into the existing roles and responsibilities of all staff.
Stages in Implementing a QA Programme
Various stages have been identified in a successful QA Programme. These include
Stage 1: Situation Analysis
To understand the local context, staff and client perceptions towards quality of health services are obtained through a series of focus-group discussions, a house-hold survey and exit interviews. A review of the health management information system makes sure that QA could be integrated into the existing health system.
Stage 2: Developing a quality culture.
Interdisciplinary quality-action teams are formed at regional, district and facility level. These teams undergo a programme of intensive orientation and training in QA skills.
Stage 3: Setting Quality indicators and standards.
District and facility-based quality indicators are developed and agreed by service providers based on local priorities and using the results from the situational analysis. The Regional QA team establishes region-wide quality standards and service providers set local targets towards achieving the regional quality standards.
Stage 4: Institutionalising the QA System.
QA systems are formalised by signing service level agreements containing explicit quality specifications. These are negotiated and agreed between regional authorities, providers and local communities, and are used as the basis for monitoring and evaluating quality of care on a continuous basis. Once QA is firmly established, benchmarking helps to identify, understand, disseminate and implement the best practice.
Devising National Quality Assurance Programmes is one thing, but their implementation at the grass root level is yet another thing. Generally, either there is no quality assurance programme in place at the peripheral level or strategies to implement quality assurance at district and sub-district level are ill conceived. This occurs despite the encouraging fact that health sector reform policies usually include quality as an explicit priority. While greater decentralisation of responsibility and resources might allow enthusiastic personnel and institutions to remedy this situation, staff need models of good practice to bolster morale and, indeed, improve their quality of care. Orientations and re-orientations are crucial to apprise the health professionals to different aspects of quality assurance.
Orientations and re-orientations are essential to introduce a QA programme, make quality assurance a habit, and maintain it indefinitely. Keeping this in view, our Institute held a 3- day State-level workshop on Quality assurance in Health Care in February 2004. The Workshop was taken quite enthusiastically by the medical profession and a total of 175 participants from different districts participated in deliberations and discussions. This was the first stage of the workshop which is to be followed in the next year with a week-long workshop to devise district-wise action plans.
The workshop was attended, among others, by experts from the Directorate of Health services, Kashmir, the SK Institute of Medical Sciences, Srinagar, and the Regional Institute of Health and Family Welfare, Dhobiwan .
Table XIII: Course Curriculum of Workshop on Quality Assurance in Health Care held in February 2004.
- Quality, Quality Control, Quality assurance and Total Quality Management
- Quality Assurance: Role of the Health Providers
- Quality assurance: Role of the Consumers
- Quality assurance in Public Health
- Quality Assurance in Maternal and Child Health
- Quality assurance in Antenatal Care
- Quality Assurance in the Care of Neonate and the Young Child
- Quality Assurance in Sputum Microscopy under the RNTCP
- Quality Assurance in HIV/AIDS Control Programme