Quality of healthcare is the extent to which healthcare services provided to individuals and patient populations improve the desired health outcomes. Quality improvement (QI) efforts aim to increase the probability that the care provided is safe, timely, effective, efficient, equitable and patient-centered. Inherent in any QI endeavor is the ability to know the current level of performance and whether the efforts have led to improvement in the quality of care. Therefore, having a robust quality measurement mechanism is of paramount importance in a health system working to increase the value of the care provided.
India, and other low-middle-income countries (LMIC) are at an important juncture now, especially for maternal and neonatal healthcare services. To meet the Millennium Development Goals, coverage of both facility-based curative and community-based preventive and promotive maternal and neonatal care has increased at a rapid pace over the last decade. The need to focus on improving the quality of care is now being realized. The Every Newborn Action Plan and Sustainable Development Goals have further emphasized the work needed to improve the quality of perinatal care. The Every Newborn Action Plan envisions to end all preventable newborn deaths and stillbirths by 2035, and one of the strategic objectives outlined to achieve this goal is to improve the quality of maternal and neonatal care. In this direction, there is a need to have a framework of quality reporting and monitoring in place to inform the QI efforts at different levels of the healthcare system. One such framework proposed by the World Health Organization (WHO) defines eight domains of quality of care that should be assessed, improved and monitored within the health system. These domains include evidence-based practices for routine care and management of complications, actionable information systems, functional referral systems, effective communication, respect and dignity, emotional support, competent and motivated human resources, and availability of essential physical resources. In accordance, WHO has published standards for improving the quality of maternal and newborn care in health facilities. However, these standards are restricted to events around childbirth and do not address the quality of care provided to small and sick neonates. Close to 600 newborn special care units are now functional in India, providing care to thousands of sick and preterm neonates. However, many quality gaps have been highlighted in the facility-based neonatal care and there is a need to define standards for care of small and sick neonates and monitor the quality indicators.
A ‘Quality measure’ consists of a descriptive statement and has following parts: (i) Data elements that are necessary to construct and report the measure with detailed specifications that direct how the data elements are to be collected and the population on whom the measure is constructed; (ii) Timing of data collection and reporting; (iii) Analytical models used to construct the measure; and (iv) the Format in which the results will be presented. Data collected for quality measures can be used for conducting audits and for informing QI programs (Table I). While developing and selecting quality measures, a balance needs to be maintained between comprehensiveness and feasibility. The chosen quality measures should fulfil all of the following criteria: (i) relate to problems with a large health burden; (ii) capture a significant leverage point in the care process; (iii) evidence that the quality of care is either variable or substandard; and (iv) information collected is usable by stakeholders.
While developing quality measures, both deductive or inductive approaches can be used. The deductive approach is based on evidence-based quality of care concepts and effectiveness of available interventions. The inductive approach is based on the existing data demonstrating either variation in care or substandard care. In view of limited existing data on quality of care, a combined approach utilizing both deductive and inductive methods is most feasible for LMICs like India.
A conceptual framework is useful while developing a family of quality measures related to a healthcare area. The framework proposed here utilizes two approaches to the quality of healthcare – the Donabedian model of dividing the healthcare into structure, process and outcomes, and the Institute of Medicine’s (IOM) six aims of providing healthcare which is safe, timely, effective, efficient, equitable and patient-centered care (Web Table I). This type of comprehensive quality measurement strategy is especially relevant in LMICs with weaker health systems. In such a scenario, targeting only healthcare processes for improvement without concurrent strengthening of structure can lead to non-sustenance of improvement in processes and failure to improve health outcomes [15].
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This special issue of Indian Pediatrics (September 2018; Volume 55: Number 9) highlights mechanisms that can support health care providers in using various quality improvement (QI) approaches and showcases some of the improvement projects undertaken in India by different teams.
The USAID ASSIST Project started working in India in September 2013; initially working directly with districts and facilities to help them learn how to use QI approaches to save lives. This work went well and the staff in these facilities were able to reduce perinatal mortality by 15% over 18 months. During this time, we met great partners from important organizations and institutions across India.
These institutions are now leading a growing movement to help more people apply QI methods to deliver care that prevents harm, improves outcomes, and meets the needs of the people receiving it through their own networks using domestic funding; continuing these lifesaving efforts after ASSIST technical support has ended.
The supplement shows important results of the ongoing QI work in these networks and shows how domestic QI networks, earlier supported by ASSIST, are now independently supporting and spreading the use of QI methods to provide better care.