Experts Build Consensus Around Quality Assurance in the Private Sector

On March 3, 2005 experts in quality assurance in domestic, international, public and private health care convened in Washington, DC for a dynamic panel discussion sponsored by the Private Sector Partnerships-One project. The goal of the panel discussion was to build consensus around quality assurance tools and approaches that can be adapted and applied to private sector reproductive health services in developing countries. Issues identified by Dr. James Heiby, Medical Officer (USAID/GH/HDN), included:

1) who constitutes the private sector;
2) why and what motivates the commercial private sector to change and improve quality of services;
3) what makes change more attractive to a private provider (i.e. evidence, demand by clients, avoiding sanctions, incentives, advantages of new ways); and
4) what are effective and efficient ways of supporting improvement in the private sector?

Order copies of the archival CD-Rom from this panel here.

View video highlights from this event here.

Panel Agenda and Highlights:

Susan Wright, USAID’s Cognizant Technical Officer for PSP-One, set the stage for the panel. “Improving the quality of reproductive health services in developing countries is central to USAID’s strategy for meeting global reproductive health needs,” she said. Wright was followed by “Voices from the Field,” recorded interviews with providers of RH services in Bolivia, Peru, Uganda and Jordan, who reiterated the pressing need for work in the private sector, especially in promoting the availability and use of achievable standards of care, providing flexible training opportunities, and establishing a sustainable accreditation system. Dr. Mary Segall clarified the purpose of the three panels was to focus on tools and approaches used for problem identification, problem solution, and system changes required including identifying what motivates providers to invest in quality improvement initiatives. Panelists from USAID, EngenderHealth, IntraHealth, URC/Quality Assurance project, the International Planned Parenthood Federation, the National Committee on Quality Assurance, Kaiser Permanente, and the Institute for Health Care Improvement all presented the state-of-the-art in their respective areas, from performance improvement models, different types of recognition for the provider and facilities, to the breakthrough series collaboratives. Each panelist discussed the adaptation of their tool or approach to the private sector in developing countries.

Panel 1: Foundation Building

The overall theme of Panel 1 was to describe the importance and use of standards and tools for assessing and improving the performance of providers and the quality of health services. The challenges of applying these tools in the private sector were identified.

1. Dr. Carlos Huezo, PSP-One, described a framework focused on the rights of the clients and needs of the providers used by the International Planned Parenthood Federation (IPPF). He then traced the process by which this framework was translated into action in 34 countries where IPPF had member associations. Challenges in meeting the needs of providers in the private sector for training, infrastructure and supplies, guidance, back up and feedback were discussed.

2. Maj-Britt Dohlie, representing the Acquire Project, described the tools constituting the Quality Improvement package with emphasis on the tools used during a COPE (Client Oriented Provider Efficient Services) exercise. Examples of their application with private sector facilities in Tanzania and Kenya were presented. Challenges & issues with the private sector were: 1) motivation to use COPE, 2) support and monitoring to assure quality among private providers, and 3) educating the clients.

3. Lauren Crigler, IntraHealth/PSP-One, described the history of performance improvement, i.e., originated in the private sector for industry and then its adaptation to the public sector in health. Five performance factors were presented: job expectations, performance feedback, motivation and incentives, environment and tools, and knowledge and skills, with application in both the public and private sector.

Panel 2: Recognition as an Incentive for Private Provider

This panel focused on the role on non-financial incentives in improving performance and quality. Two panelists presented different examples of recognition as an incentive for the private sector.

1. Rebecca Furth, Initiatives Inc., described an approach used in Jordan to sustain quality improvement by recognizing facilities that met performance standards and received a plaque as the reward. Questions for the private sector include: Identifying who are the providers? Whether quality improvement will increase market share? Is there a regulatory body to set and assess compliance with standards? What opportunities for collaboration exist between private and public sector in terms of improving quality?

2. Alan Hoffman, National Committee for Quality Assurance, described the physician recognition program and its relevancy to health improvement in developing and middle-income countries. The physician recognition program evaluates clinical care and the care system for diabetes and heart/stroke. Performance standards are identified and different methods for determining physician adherence to the standards are applied. The outcomes of the program are disseminated so that the public is informed if a particular physician has received this certification. The speaker suggests that this recognition model can be adapted to preventive care and other chronic care conditions including HIV/AIDS.

Panel 3: Improving Systems of Care:

1. Alide L. Chase, Kaiser-Permanente, described how they use their integrated structure to drive clinical performance improvement. Incentives for ongoing quality/service performance improvements are built into annual agreements between the health plan and medical group.

2. Dr. Rashad Massoud described the Institute for Healthcare Improvement’s (IHI) strategic plan and activities. The Collaborative Improvement Model was highlighted as a way of sharing knowledge and efficiently scaling up improvement efforts. IHI’s relationship with Kaiser Permanente was then presented as an example of a strategic partnership for healthcare improvement.

3. Dr. David Nicholas, University Research Co., summarized some basic principles of quality assurance and improvement, including tools and approaches. He then described the improvement collaborative method, including examples of how the Quality Assurance Project has been successfully using the method in Russia, Latin America and Africa.

Dr. James Heiby of USAID closed the day by summarizing salient issues from the discussion. “The fields of quality improvement and performance improvement have experienced impressive advances in recent years. The technical feasibility of improving quality with these robust approaches is encouraging,” he said. It is important that PSP-One and those interested in improving private RH service delivery focus on the central role of motivation and incentives in influencing the behavior of private provider, sustaining improvement, and documenting lessons learned. One of the working groups agreed wholeheartedly about the need to know more about the quality of services provided by the private sector.

The next steps for the Quality Assurance component of PSP-One include:
1)Conducting a desktop review of quality activities in countries receiving USAID assistance;
2) Holding a 1-day working group with interested parties to review the desktop review concerning what is known about the quality of services provided by the private sector (both commercial and NGOs)
3) Agreeing upon a “bundle” of interventions that could be tested in different countries with specific groups of private providers (e.g. GPs and midwives) to determine effectiveness in improving quality of services.
4) Identifying other mechanisms for interested parties to work together on improving quality in the private sector.