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1. Introduction to Health Care Quality

2. Module Objectives
By the end of this session participants will be able
to:
 Discuss the context of health care in Ethiopia
 Identify key quality gaps in Ethiopia health system
 Define quality in health care
 Identify the key drivers of improvement in health care

3. Introduction
Reflection questions
 What is the current structure of health care in Ethiopia?
 What are the four transformation agendas?
 What is quality in health care?
 What are the six dimensions of health care quality?
 What are some causes of poor quality?
Time: 10 minutes

4. The Ethiopia Health Care System
 A health system is the organization of people,
institutions and resources that deliver health
care services to meet the health needs of target
populations
 And as such, with the vision “To see healthy,
productive and prosperous Ethiopians” the
Ethiopian health care system is currently
arranged in a three tier system

5. The Three Tier System
Specialized Hospital
(3.5-5.0 million people)
General Hospital
(1-1.5 million people)
Health Centre
(40,000 people)
Primary Hospital
(1-1.5 million people)
Health Centre
(25-40,000 people)
Health Post
(3-5,000 people)
Urban Rural
Tertiary level health care
Secondary level health care
Primary level health care
Ethiopian Health Tier System

6. Transforming The Ethiopian Health
Care System
 The Health Sector Transformation Plan (HSTP)
2015/16 – 2019/20 (2008-2012 EFY) is currently
being implemented across the health sector
 There are four transformation agendas outlined
1. Quality and Equity
2. Woreda Transformation
3. Information Revolution
4. Compassionate and Respectful Care (CRC)

7. The Ethiopian National Health Care
Quality Strategy
 The Ethiopian NHCQS, launched in 2016, builds
on the plan laid out in HSTP to further align key
stakeholders across 5 prioritized interventions,
which are:
 Maternal and Child Health
 Nutrition
 Communicable Diseases
 Non-communicable Diseases
 Clinical Services

8. Definition of Quality in Healthcare
“The degree to which health services for individuals and
populations increase the likelihood of desired health
outcomes and are consistent with current professional
knowledge”
Institute of Medicine (IOM) 2001
”Comprehensive care that is measurably safe, effective,
patient-centered, and uniformly delivered in a timely way
that is affordable to the Ethiopian population and
appropriately utilizes resources and services efficiently”
(NQS 2016)

9. Six Dimensions/Domains/of Quality in
Healthcare
Reflection question:
 After watching the short video, reflect on the following
questions:
 How did this woman’s story make you feel?
 What were the key learning points for you as a health care
provider in the perspective of quality?
– What went well for this woman?
– What were some of the problems this woman encountered?
– What could be done differently?
 What aspects of quality do you identify from the women’s story?
 Time:16 minutes

10. Six Dimensions (… cont’d)
 List the dimensions/domains/aims of quality by
IOM

11. Six Dimensions (… cont’d)
1. Safe
 avoiding injuries to patients from the care that is
intended to help them
2. Timely
 reducing waits and sometimes harmful delays for
both those who receive and those who give care
3. Effective
 providing services based on scientific knowledge to all
who could benefit, and refraining from providing
services to those not likely to benefit

12. Six Dimensions (… cont’d)
4. Efficient
 avoiding waste, including waste of equipment,
supplies, ideas and energy
5. Equitable
 providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity,
geographic location and socioeconomic status
6. Patient-centered
 providing care that is respectful and responsive to
individual patient preferences, needs and values, and
ensuring that patient values guide clinical decisions

13. Group Exercise Instructions
 Divide into five groups (4-6 participants/group)
 Read the case study from the participants manual
(page 17)
 Discuss how the six dimensions are reflected on the
case study
 Prepare your response with flip chart for plenary
presentation and discussion
 Time: 20 minutes

14. Case Scenario
A woman presented at a hospital with an acute watery diarrhea. She
was admitted, she was re-hydrated and other treatments given as per
the guideline. Her care team, to follow standard precautions, isolated
the patient so that the disease was not transmitted to others, and
ensured that everyone wore personal protective equipment at all times
when in contact with patient or environment. The patient was very
modest and shy so the team ensured that she was cared for by a
female nurse and that her body was not seen by men. The hospital had
a process for cleaning and disinfecting her soiled clothing safely. The
team provided information about the risk of transmission to all the
health care workers, and used the case to reinforce the use of isolation
precautions when necessary with all health care workers. The team
provided information to families and the community about prevention
and care of patients.

15. The Donabedian Framework
The “Donabedian model” is a conceptual model
that provides a framework for examining
health services and evaluating quality of health
care
 Structure: The context in which care is delivered
 Process: Transactions between patients and
providers
 Outcome: Effects of health care on the health status of
patients and populations

16. Patient/Client Definition of Quality in
Healthcare
“Don’t Harm Me”
“Heal Me”
“Be nice to me”
How does patient/client define quality?
In this order…

17. Core Elements of Quality in Healthcare
Juran’s Trilogy
Quality
Control

18. Quality Planning Policy, resources, coordination,
accountability, execution design
Quality Planning, Quality Control and
Continuous Quality Improvement
Continuous Quality
Improvement (CQI)
1. Aims: what are the “gaps”
in performance and outcomes
2. Measures: tools to
measure and feedback
processes and outcomes
3. Changes: QI change
activities for leadership, admin
and frontline to close the “gap”
4. PDSA
IMPROVED
OUTCOMES
Standards/
Guidelines/
protocols
Professional
oversight
Accreditation
Performance
review
Quality Control (QA)
© 2012 P Barker/L Provost

19. Juran Trilogy: All Three Core Elements
are Needed
OPERATIONS
TIME
Quality Control (During Operations)
Time

20. Key Drivers of Improvement in HC
Building Will
Executing and
spreading
change
Methods for
Systems
Improvement
Financing
Workforce
Governance
Drugs and supplies
Information systems
Delivery systems
Having the Will (desire) to change the
current state to one that is better
You must have Ideas about
alternatives to the status quo
Having the capacity to apply QI
theories, tools and techniques
that enable the Execution of
the ideas

21. Summary
 The Ethiopian health service is currently structured
into a three tier system
 The HSTP has prioritized “quality and equity” as a
core agenda, and the NQS has prioritized areas to
actualize the agenda
 Quality in health care has different definitions. A
commonly used one is the IOM definition
(STEEEP)
 The drivers of improvement are will, ideas and
execution