Dr. Heiby Answers Questions from PSP-One Community
In July 2005 PSP-One interviewed Dr. James Heiby of USAID about improving quality of health care systems. View this original dialogue. The PSP-One community then had the opportunity to ask Dr. Heiby questions. Below we list these questions, and Dr. Heiby's responses. We invite you to continue the dialogue by submitting your own answers/comments on the Q&A board. Follow links below.
Q1: from Kenneth Tawo-odu, State Program Coordinator, Hope Worldwide Nigeria
I read the article on QI and a big push is needed for such observations. This area is been almost unspoken of and untouched by Health care Administrators especially in Africa.
My concerns are multiple fold:
One: Identification of authority or policy implementers
Two: the cost.
Now there is no doubt about it that, the level of QHI indices (Quality Health Improvement) could take a giant leap if there is an articulated approach where by there will be simultaneous pilot programs that could be donor driven and civil society implemented and another reversed allowing the existing governmental infrastructure to execute such a program with donor funds. In these two scenarios it will be likely that the latest technologies will be deployed to see to its full implementation, after which the two institutions will be able to access on the level of success.
The question is can the Governments at country level be mobilized to embrace this new initiatives on an emergency scale especially if we have to put the MDGs in focus?
Dr. Heiby’s Response:
What might influence policy makers to urgently address quality issues? Certainly, donors have substantial influence, but vertical programs, focused on a specific health problem, generally have not emphasized quality improvement or other health system issues. Sector-wide approaches (SWAps) are well-suited for QI in many respects, but their focus on a few indicators to monitor progress is not a good fit. We just can’t capture trends in quality of care with a few measures. So, I see a need for a change in donor strategies if they are to make QI a priority.
If donors did make QI a priority, how could they best support policy change, considering both the cost and the effectiveness of different strategies? Kenneth suggests two useful scenarios for developing pilot programs. A closely related idea emphasizes widely sharing the lessons of local QI interventions. If, for example, a given clinic or district QI team has found a way to improve counseling in HIV testing, why shouldn’t this kind of knowledge be available to anyone facing a similar issue? Why should others need to invest in re-inventing the wheel? Currently, this kind of practical knowledge is not available through traditional information sources. A organized system, specifically for sharing improvement information, could provide not only practical models, but also help establish global community of practice in QI. [See for example, D.M. Berwick, A learning world for the Global Fund; BMJ, 2002: 325, pp. 55-56.]
Q2: Dr Dinesh Agarwal, UNFPA, India
Emphasis on keeping proper medical records of the clients is crucial for any quality assessment. However most private providers especially solo practitioners find it too cumbersome and inconvenient to maintain records. There can be several reasons for this attitude. They may be hard pressed for time as at times they have to consult a large number of clients in short time. Most doctors also don't want to get in to legal wrangles by keeping records and then making these records available to clients or other agencies. They will like to cover themselves by pretending that the no records were maintained. Also there are issues related to tax liability. They find it easy to evade taxes (income tax) by not maintaining any records. In such a situation how to motivate/ persuade doctors to maintain records for using these in quality assessment?
Dr. Heiby’s Response:
Dr. Agarwal offers interesting insights into factors that provide disincentives to private providers to maintain good medical records. A 2004 study of private providers’ management of TB cases in Cambodia reinforces the point: Nearly 70% maintained no records at all. There may be a role for technical support in setting up record systems, but first practitioners must want such a system. I have not seen much work in this area, but we can take some ideas from developed countries.
Third party payers have both the rationale and the means to demand good documentation of care from the providers that they pay. Accrediting bodies traditionally emphasize the documentation process in their criteria, providing an incentive for hospitals to maintain good records. In the US, the National Committee on Quality Assurance (NCQA) applies a similar approach to ambulatory care. As incentives, NCQA has used both public recognition of providers and monetary payments, based on documentation of high levels of quality.
A few pilot programs have offered practitioners material incentives, such as TB drugs, to keep records and report to the national program. Professional associations have also carried out programs that include improved medical records, based on promoting shared professional standards.
In developing an initiative to improve medical records, it is important to clarify how the records will be used. Experts are quick to point out that once records are used to sanction clinicians, real cooperation disappears.
Q3: from Susan Wright, USAID/Washington, D.C.
I agree with you that medical records are a key component of quality of care, and that the overwhelming majority of private health clinicians in developing countries have very inadequate records. In some cases this may be deliberate, to disguise income or particular services performed, but in many cases it may simply be due to lack of a good model or perceived incentive to do good record keeping. I also agree that job aids are sorely lacking.
Are there any good examples of medical records in the private sector that ALSO serve as job aids, by reminding health workers to assess particular variables or check that the client has received particular types of counseling or services? Also, if any of the other readers of this IQC site have examples to share, I would encourage them to do so. Thanks, Susan Wright.
Dr. Heiby’s Response:
Susan’s request to readers for examples of medical records that serve as job aids is a good place to start, given how little we know about this seemingly straightforward issue. Most of the research in this field was done in developed countries, and most of the work in developing countries was done in the public sector. But we can draw some tentative conclusions if we assume that some common principles are operating.
If the outcome we are looking for is improved provider compliance with clinical guidelines, studies suggest that we should use a multi-dimensional strategy, not rely on a job aid alone. If providers are motivated to follow the guidelines, a standardized medical record is a good option for supporting them. The IMCI chart book provides such a medical record/job aid, and this has proved essential to the initiative.
A study in Zambia to improve the design of this record can be found at www.qaproject.org under publications, “Assessing the functionality of job aids in supporting the performance of IMCI providers in Zambia.” Here you may also access “The use of manual job aids by health care providers: What do we know?” and “Helping healthcare providers perform according to standards”, for more general reviews. Related studies include “Improving the management of obstetrical emergencies in Uganda through case management maps” and “Redesigning hospital documentation systems to improve the quality of patient obstetrical records in Ecuador.” Readers can also access “Job aids symposium” for a summary of general principles in the design of job aids—especially the importance of empirical testing--as well as other case examples.
Q4: Dr. Ladi Awosika, Total Health Trust HMO, Lagos, Nigeria
The paper by Dr. Heiby is very incisive. Thanks for this insight into issues that are generally applicable to our environment. The real issue has been on how to use a carrot and stick approach to influence uptake of simple quality improvement with providers in the commercial sector. Now that people demand value for money spent and pre-paid care is assuming a greater portion of medical facility income, it would be easy to replicate the simple steps and approach that have been highlighted by Dr. Heiby.
Dr. Heiby’s Response:
Dr. Awosika points out that even when policy makers are committed to improving quality in the commercial private sector, they face a complex range of options. Most would agree that some combination of positive incentives and regulatory sanctions is most promising. Since only limited research has directly addressed how to influence private sector quality, it would be prudent to examine alternative approaches. Such an empirical approach would, in turn, require effective monitoring of quality trends.
Without doubt, examining these issues would be greatly facilitated where a health insurance organization links provider payments to measures of quality.
Q5: Eneud Sandfore Gumbo, Save the children Umoyo Networks, Malawi
Thanks for a very good discussion on QI in private sector. In your discussion, you mentioned the availability of various monitoring tools. Is it possible to share with me these tools, more especially those pertaining to reproductive health and HIV/AIDS related services?
Dr. Heiby’s Response:
It is useful to see concrete examples of tools like this, and I hope readers will provide a wide variety. Many quality assessment tools were designed for special studies and are likely to be too detailed for regular monitoring. These research instruments do, however, provide good models for framing questions and for designing forms that are easy to complete.
It is important to also consider how the monitoring process will be carried out. Most forms are designed for an independent observer, who watches the patient-provider interaction, often checking off tasks as they are done. Peers could also play this role if the instrument is clear. Studies have also shown encouraging results from self-assessment forms completed by the provider, usually with occasional verification by another observer. If the clinical record is reliable, a form designed for auditing records is faster and cheaper than observation.
A common pitfall to avoid is overloading the observation instrument with too much information. If the goal is routine monitoring of quality, the first priority is to develop a monitoring approach that is feasible under normal conditions. All such forms provide an incomplete picture of quality, but can nevertheless provide important new insights into how care is being provided. There is also a strong argument for changing the content of the monitoring process over time.
Some initial examples from www.qaproject.org include: 1) a number of instruments related to HIV/AIDS services in: The Zambia Workforce Study; 2) a discussion of the process for developing tools in: Monitoring the Quality of Primary Health Care; and 3) instruments for integrated child health services in: Assessing Health Worker Performance of IMCI in Kenya. A thorough approach to assessing family planning services can be found in: The Situation Analysis Approach to Assessing Family Planning and Reproductive Health Services [Robert Miller, et al], available through Amazon.com
Q6: from Steve Musau, Abt Associates, U.S.
One issue that seems to not receive adequate attention is the cost side of the quality improvement debate. What are the cost-related incentives for quality improvements? Is there any data that demonstrates the benefits of improvements in the quality of health care, and what areas (e.g. in a hospital) have the highest return per dollar invested in quality improvement?
Dr. Heiby’s Response:
Quality improvement activities use resources, and they should be held accountable, particularly in developing countries. There are distinct issues related to 1) the direct cost of improvement activities, and 2) changes in the cost of health services as a result of QI interventions.
The direct cost of QI activities include staff time, training in QI methodologies, and relatively modest ongoing support. To be justified, QI needs to produce benefits greater than these costs. Recent developments in the field have focused on increasing the cost-effectiveness of QI. The central idea is to expand the benefit of a successful QI effort in one facility by spreading it to many other similar facilities. A promising model for scaling up improvements is known as the spread collaborative. Since most programs make only minimal investments in QI, it may be too soon to assess overall return on investment.
The impact of QI on the cost of services varies. In examples that can be found at the above web site, helping providers follow guidelines for child health in Niger reduced costs by eliminating wasteful use of drugs. In a study in Russia, bringing the care of pregnancy-induced hypertension into line with evidence-based guidelines, dramatically reduced costs by eliminating needless hospitalizations. In other cases, improved quality may involve increased costs. But the design of QI interventions can include specific cost constraints from the beginning—there’s little reason to test a change that is unaffordable.
In developed countries, third party payers, such as health insurance companies, have shown a growing interest in linking quality of care to how much providers are paid for their services. The impact of pay-for-performance is surprisingly complex, but developing country applications are also expanding [see for example, P. McNamara, Quality-based payment: six case examples; International Journal for Quality in Health Care 2005: Vol 17, no. 4, pp 357-362].
I would like to thank the readers for their insightful comments and thought-provoking questions.
