Jump-Starting Progress on MDGs 4 and 5 through Quality Improvement
09/16/2010
URC Senior VP M. Rashad Massoud says traditional approaches to improving health care systems are not enough
The 2010 Millennium Development Goals report paints a stark reality. While there are many examples of where selected interventions are gaining traction, overall, for developing world as a whole, progress on MDGs 4 and 5 has been falling short of targets, especially for maternal and newborn mortality reduction.
The problems driving this weak performance on key health outcomes are also familiar. As Dr. Margaret Chan of WHO put it so aptly, the power of our interventions and all the evidence behind them, is not matched by the power of our delivery systems to make those interventions available broadly and reliably to large numbers of people.
Our traditional approaches to improving health care delivery systems - standards and guidelines, training, making life-saving drugs more widely available - are all essential components of improving health systems. But they are not enough. The MDG lags are testimony that these approaches alone are not enough because they tend to address only the inputs to health systems and do little to affect the processes of health care delivery.
When we peer inside the "black box" of how health services are routinely provided, we frequently find large gaps between standards of care and the care actually provided. For example, while most countries have made substantial progress in extending coverage of antenatal care at least once during pregnancy, when assessments actually look at the content of that care, many programs fall short - missing key opportunities to provide impactful counseling that truly improves birth readiness and knowledge to act when something goes wrong. Similarly, when we actually measure whether critical elements of essential obstetric, such as active management of the third stage of labor, are provided in facilities, we often find serious gaps in quality. Such findings mean that huge international investments to get the right drugs and equipment in place and encourage more women to seek skilled attendance at birth are wasted, because key care delivery processes failed.
So, what approaches are available to focus on the process and reach better outcomes? Quality improvement methods build on traditional input-focused approaches like standards and training, but go well beyond them to guide frontline health workers to find concrete ways to change their care processes to yield better outcomes.
Quality improvement is a scientific approach to change. It engages ordinary health-care providers to change what they do. It is bottom-up change that empowers health workers to do things differently at the point of service delivery and be accountable for their results.
It rests on a rather simple conceptual model that asks three straightforward questions: What are we trying to accomplish? How can we measure that? What changes can we make in how we organize and carry out care processes to improve them? Improvement also relies on several common-sense principles: relying on teams of providers to make changes in their own systems, addressing client needs, and using data to measure results. We like to call it the Science of Improvement because it is based on systematic, data-guided activities specifically designed to introduce changes to systems of care delivery and bring about prompt and measurable results in the performance of health systems.
And the evidence for the effectiveness of improvement approaches is growing rapidly. We have seen in countries as resource-constrained as Niger and Afghanistan that large-scale improvement in maternal care processes is possible, to make a measure gains in service quality that the lead to better outcomes. We have seen national scale-up of quality-focused essential obstetric and newborn care in Ecuador, and many other examples in child health and HIV care. Our analysis of the work of more than 1,300 quality improvement teams in 27 countries demonstrated that teams were able to achieve performance levels of 80 percent or higher for 88 percent of the indicators studies, and 76 percent reached performance of 90 percent or higher, even though two-thirds had baseline performance below 50 percent. Across the countries, regardless of baseline and topic, teams achieved average increases of 52 percentage points per indicator measured.
Improvement efforts may follow different methodologies - there are many that have been shown to produce compelling results. We have learned a great deal in the past 20 years about how to do improvement efficiently and at scale and what factors are important in achieving results - like champions, having specific goals, using incentives for quality, and planning for scale-up and sustainability. We have found that getting many health teams focused on solving related problems at the same time, such that there is concentrated learning about how to improve specific care processes in the local setting, is extremely efficient and effective. It gets everyone moving in the same direction and increases the pace of change.
We now have very efficient strategies for overcoming barriers to improving health-care processes with a clear focus on linking those efforts to outcomes. One approach is collaborative improvement, which harnesses the ingenuity of many teams, sharing what they are learning with their peers and supervisors. We have found this approach to be incredibly motivating to people. It makes them want to do better and gives them a pathway for doing so. When teams hear how another team has done something innovative, they often react, if that team can do it, we can, too. Such efforts create a system for learning and accountability that produces results.
We are not yet at the tipping point of widespread application of quality improvement in all countries. But those countries that are moving forward with data-driven improvement are helping to create a critical mass oriented to and capable of improving care and achieving the MDGs. The relatively rapid results that can be achieved in improvement, across many teams, and their ability to provide a path for scale-up - doing more of what we know works - makes improvement methods a logical strategy for jump-starting our efforts to reach the MDGs.
Learn More
How Quality Improvement in Health Care Can Help to Achieve the Millennium Development Goals
M. Rashad Massoud, MD, MPH, FACP is director of the USAID Health Care Improvement Project and senior vice president of the Quality and Performance Institute at University Research Co., LLC - Center for Human Services.
I agree completely. Institutionalization of QI holds a great potential for sustained progress on attainment of MDGs and any other health goals for that matter. Health care workers at operational level derive much motivation from taking responsibility for improvement, implementing their interventions and tracking the progress.
— Jacqui Sekgothe Molopyane on 2010-09-27
I’m a graduate Public Health student taking a Quality Assurance class. I also work for Ministry of Health in a developing country and couldn’t agree more with the case Dr Massoud’s makes for QI in health care delivery. Processes in health care have not been given half as much attention as they deserve, and improvement methods have almost always ‘come from above’, with front-line providers and communities only seen as implementers and recipinets, respectively. A shift in approaches is long overdue
— Kenanao Motlhoiwa on 2010-09-30