VU University Amsterdam Quality Improvement Health Care Delivery Hospital Quality Low and Middle Income Countries Developing Countries Resource-Restricted Settings

1. International Standards,
Local Solutions
Improving quality of care in resource-poor settings
Michael Johnson
VU University Amsterdam

2. Moshi, Tanzania

3. Quality, Distance, and Cost
Kilimanjaro Christian
Medical Center
Kilema District Hospital

4. Quality in low-resource settings:
from a vicious cycle to a virtuous cycle
DemandDemand SupplySupplySupplySupply
PatientPatientPatientPatient
QualityQualityQualityQuality

5. The SafeCare Initiative
PharmAccess International
Foundation, the Netherlands
The Council for Health Service
Accreditation of Southern Africa
South Africa
The Joint Commission
International, USA

6. Why create something new?
1
2
3
4
5
Tertiary (teaching) hospital- providing majority
of specialized medical care .
Referral hospital providing a broad spectrum
of medical care
Primary health center (minimum one MD,
nurse and lab technician)
Basic health center offering primary health
and maternal care(min. one clinical officer)
Health shop/nurse driven clinic: advice on
basic health care issues6
District Hospital (or faith based/private
hospital) providing 24 hrs services

7. How much quality do you need?

8. Quality Assessment with the
SafeCare Standards

9. • Desire to improve
• Lack funding or resources for complete overhaul
• Need to assess the facility, identify priority improvements
Source: Umar 2009

10. It’s amazing! What is it?
Certification
Quality Improvement Risk Management
Quality Assessment

11. Research Aim
Was SafeCare developed in the right way?
Are there any gaps?
Research Question
How can SafeCare adapt their
quality assessment framework
in light of academic literature?

12. Research Sub-Questions
Case Study
1.How were the SafeCare Standards developed?
a. Which resources formed the basis of the development of the
SafeCare Standards?
b. What were the primary guiding principles behind the
development of the SafeCare Standards?
c. How were the SafeCare Standards adapted to fit low-
resource context in sub-Saharan Africa?

13. Research Sub-Questions
Case Study
Analysis
2.How can the SafeCare framework for health care quality assessment be
described?
3.How does academic literature on health care quality assessment in
developing countries relate to the SafeCare Standards?
a. What are the primary authoritative resources about health care
quality assessment in developing countries?
b. How do the findings from these resources relate to the SafeCare
Standards?
2.Comparing the results from Question 2 and 3, what are lessons
SafeCare could learn and adapt into their framework for health care quality
assessment?

14. Methods
• Literature review
– Accreditation, standards, quality assessment, developing
countries
• First round of interviews
– Develop guiding principles
– Broaden base of background literature
• Second round of interviews
– Validate findings
– Identify specific recommendations for improvement
• Second literature review

15. Results
• Case Study
– Resources

16. Results
• Case Study
– Resources
– Guiding Principles
• Feasible
• Realistic
• Scalable/Sustainable
• Institutional Framework

17. Results
• Case Study
– Resources
– Guiding Principles
– Adaptation
• Input from conference of experts: Doctors,
nurses, laboratory, pharmacy, operations,
finance, IT, epidemiologists
• Pilot testing at small and large facilities in
Tanzania

18. Results
• Case Study
• Analysis
– Academic literature on quality assessment
• Sources, local adaptation, validation, revision (Shaw)
• Structure, Process, Outcome (Donabedian)
• Benchmarking:
– Requires good data
– Focused on outcomes
– Comparing processes is difficult

19. Preliminary Conclusion
• What can SafeCare learn and adapt
into the quality assessment framework?
– Documenting the process
• Show link to academic research and local &
international guidelines
– Explain the priorities: which standards are
most critical to patient safety and risk?

20. Preliminary Discussion
• Limitations
– Bias in interviews
– Volumes on quality. Little on small
facilities.
– Findings are not transferrable because of
complex social/cultural factors

21. Preliminary Recommendations
• Impact Assessments
– Short term: acute disease, surgery care
– Long term: chronic disease, maternal care
– Process measures
• Quality Teams at each facility
• Data-Mining for insights

22. The End

23. Future Research Opportunities
• What is quality improvement?
• What works and why?
– to unpick the complex relationship between context, content, application
and outcomes, and to develop a necessarily contingent and situational
understanding of effectiveness. Walshe, 2007
• How should it be measured?
• Will patients pay more for quality?

24. References
• Umar, N., Litaker, D., & Terris, D. D. (2009). Toward more
sustainable health care quality improvement in developing
countries: the “little steps” approach. Quality management
in health care, 18(4), 295–304.
doi:10.1097/QMH.0b013e3181bee28d