Quality of Care: A Strategic Leader’s Approach

Recently, I proposed to a potential client, a large multi-national organisation, how I would approach issues around safety and quality of care for their facilities in 120 countries worldwide. I later realised that the ideas I shared could benefit other leaders in the healthcare industry irrespective of the size of their organisation.

I’ve summarised my main points based on the following four thematic areas, covering a variety of quality improvement issues that healthcare leaders face on a day-to-day basis.

• How to safeguard and strengthen the quality of medical services in an organisation
• My top 5 KPIs on clinical safety and quality of care and how to enable measurement and reporting
• How I would support a colleague facing community protest because of a maternal and neonatal death
• How to minimise and mitigate risks and influence decision-makers to mobilise resources to enable safer and high-quality medical services

How to safeguard and strengthen the quality of medical services in an organisation

Service delivery is an essential part of the six health system building blocks. To deliver good quality services effectively, there must be a mechanism to monitor the services to inform action for improvement.

Starting from the starting line

The best starting point is by first understanding the current level of quality from existing data to guide the development of interventions. However, because there is currently “limited or no information on the safety and quality of clinical care provided”, I would start with a baseline assessment of the healthcare facilities under my care. The baseline assessment would seek to obtain information on basic quality indicators according to the Donabedian quality framework of structure, process and outcomes, as follows.

The Donabedian quality framework

• Structure: Are the minimum requirements for quality care met? These include staff, equipment, supplies, guidelines, policies, job aids, etc.
• Process: Are the right processes and guidelines followed in delivering care? For example, respectful care, privacy, delays (e.g. decision-to-action for emergencies), etc.
• Outcomes: What results do we get from delivering care? I would focus on mortality rates (such as stillbirth rate, neonatal mortality rate, case fatality rates, etc), patient satisfaction, complications rate, etc.

What to do with the baseline assessment

The results of the baseline assessment should guide where our focus should be from the organisational perspective and help to identify the right quality improvement approaches to be used. However, each health facility is unique in many ways and there may be the need to tailor our approach according to the priority needs of individual health facilities.

Using the results of the assessment, I would consider introducing quality improvement methods, such as maternal and perinatal death audit and standards-based audit. The aim of these interventions is to ensure the maintenance of the essential dimensions of quality, i.e. safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness.

Introducing specific quality improvement methods

Maternal and perinatal death audits are useful quality improvement methods, especially in settings and facilities where mortalities are high, such as facilities with inpatient capacities. I would also introduce standards-based audit (also known as criterion-based audit) in all clinics and outreach teams since it does not depend on the occurrence of a specific event, such as mortality. It is a quality improvement method used by healthcare providers to measurably improve the quality of care.

To introduce the quality improvement measures outlined above, I would work with colleagues within the organisation and consult widely with other stakeholders in the target communities to develop a programme.

We would aim to train all staff directly involved in the delivery of care on quality improvement. Each facility should select a multidisciplinary team to be responsible for conducting quality improvement activities, such as conducting an audit and documenting and reporting activities.

Supervision is key…

I would support supervision mechanisms to provide staff with more opportunities to clarify any practical challenges they might have encountered in their practice. This should also give a better view of practical problems in implementing quality improvement activities and use that as feedback to improve our approach and/or its implementation.

A quarterly workshop should be organised by countries, regions or districts (depending on the scale of our operation) to provide a forum where staff could share their progress on quality with staff from other facilities/teams, discuss challenges and proffer solutions together.

My top 5 KPIs on clinical safety and quality and how to enable measurement and reporting

It is essential to measure healthcare quality. This measurement is enabled by monitoring key performance indicators (KPIs), which help us to identify areas of high or low performance for possible further investigation.

Because quality has different frameworks and different perspectives, I would attempt to select key performance indicators that focus on the most important issues. Below are the top 5 KPIs I would choose. However, before finalising the list, I would consult with other colleagues and stakeholders for their inputs, pilot test the KPIs and review as necessary.

Top 5 KPIs for quality of care

1. Health outcomes: These include neonatal mortality rate, stillbirth rate, case fatality rates for specific diseases, etc. These are useful in measuring the effectiveness and timeliness of care provided.
2. Patient safety: This can be measured through proxy indicators, such as rate of medication errors, hospital-acquired or post-operative infections or other complications, etc.
3. Staff-to-patient ratio: The availability of a skilled healthcare provider is one of the single most critical factors affecting the quality of care provided to patients. Thus, this ratio is an important indicator of quality care.
4. Patient satisfaction: No matter how well care is organised and delivered, it is important that it meets patients’ needs and aspirations. Patient satisfaction addresses the patients’ perspective on quality. Example: the proportion of patient satisfied with emergency services.
5. Service utilisation by patients: e.g. hospital births, immunisation uptake, antenatal attendance, etc. They indicate how acceptable services are to the community.

Enabling reporting of KPIs

Some of the above indicators are already measured and reported by countries, while others (such as patient satisfaction) are rarely measured. Therefore, countries may need support to do so.

First, there should be a need to build the capacity of stakeholders to enable them to capture the right indicators correctly. Updating the organisation’s policy documents, guidelines and standard operating procedures (SOPs) to include the new indicators will provide a reference guide for adoption into practice.

In countries with existing national data reporting systems, such as the District Health Information Software (DHIS), it would be recommended to include these indicators into the system. This would ensure continuous measurement and reporting.

Advocacies to stakeholders, including ministries of health and professional bodies, could increase awareness and help to facilitate faster the adoption of the new indicators.

How I would support a colleague facing community protest after a maternal and neonatal death

Maternal and neonatal deaths are stressful events not only to the relatives of the deceased but also to healthcare providers.

In this scenario, there are three phases of action I would consider:

• Take immediate action to avoid further escalation of the situation.
• Review/audit the circumstances that led to the death of the mother and the baby and take action to avoid future occurrence.
• Continuous engagement with the community to restore people’s trust in the clinic.

The immediate step…

To prevent further escalation, my first priority in this scenario would be the safety of staff and other patients in the clinic. I would try and calm the Clinical Lead down through a phone call, if possible. Then, I would ask her a few questions to understand the situation better. For example, I would ask if she is safe, how many people are in the clinic, whether the police involved, and so on.

I would advise that she reaches out to the police and/or an opinion leader in the community if it is possible to do so, to help calm down the crowd. In the meantime, she should avoid any action that would lead to further escalation, such as confrontation.

When the situation is diffused, I would encourage the Clinical Lead to initiate community engagement activities to restore a friendly relationship between the people in the community and the clinic staff.

If possible, I would join in some of these activities and would encourage the Country Director to do so, as well. We would visit community leaders and reassure them of our commitment to serving the community. This will demonstrate to the people that we care and we would take all necessary actions to prevent similar events from occurring in the future.

Reviewing the deaths

Once the clinic resumes normal working activities, I would support the Clinical Lead to conduct a thorough maternal and perinatal death audit to identify the causes of, and factors that might have contributed to, the two deaths.

Recommendations should be drawn from the findings of the audits and staff should be assigned responsibilities for actions, with deadlines for completion.

Continuous engagement

I would encourage continuous community engagement. For example, the Clinical Lead can include a member of the community to represent the community in the clinic’s quality improvement committee.

The clinic could also create a “Clinic Friends Committee”, which is entirely made up of opinion leaders from the community and could serve as an advisory group to the clinic and as an effective communication channel between the community and the clinic. This has been implemented elsewhere very successfully.

How to minimise and mitigate risks and influence decision-makers to mobilise resources for safer high-quality medical services

Maintaining a high level of quality is the best approach to minimising the risk of negligence and malpractice. I would encourage the establishment of quality improvement processes, systems and teams in each clinic that we run.

Continuous quality improvement 

For facilities with inpatient capacities, each team should be trained on how to conduct a maternal, perinatal and standards-based audit. Outreach teams, which are less likely to record mortality, should be trained on how to conduct a standards-based audit. Teams should also be trained on how to investigate and report critical incidents.

All teams should be supported to develop a clear action plan to raise and/or maintain a high level of quality care. The training should empower the teams to not only identify quality issues by themselves but also act to solve problems and prevent adverse outcomes.

I would create templates and forms needed to conduct audit and report incidents and provide support teams to take action and execute their plans. Crucially, I would work with teams to develop a culture of quality in all aspects of care.

Developing standards for a better quality of care

I would work with other colleagues to develop standards of care for the most common diseases/conditions seen by our staff. First, we would review the literature to identify best practices. We would then tailor the standards according to the needs of the community we serve and any available local guidelines. Before deploying the standards in the field, we may invite external reviews by experts and other stakeholders. Then, we would implement a standards-based audit in cycles.

The standards-based audit cycle

1. Select standards for audit – we can use a matrix to help clinics/teams to select serious and frequently-occurring problems first
2. Take a baseline measurement of compliance with the selected standards
3. Share feedback and identify changes in practice required to increase compliance with the standards
4. Implement the changes identified
5. Reassess standards to check any changes in compliance from the baseline.

Clinics/teams should then select another standard to audit and the cycle continues.

Engaging decision-makers and mobilising resources for quality care

To influence decision-makers and mobilise resources for safer medical services, I would advocate for the inclusion of key performance indicators related to the quality of care we provide, if not already captured, into regular reports. This would allow for continuous monitoring of the quality of services provided to clients and help keep quality at the top of decision-makers’ minds.

I would also create and share special reports on the quality of care we provide, showcasing achievements and highlighting areas of improvement. These will become valuable tools while advocating for resources to improve the quality of care we provide.

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