Policy Interventions to Improve Quality
The success of quality improvement policies can be measured by their ability to raise the average level of health and reduce variation in quality. Two types of policies are intended to improve quality and thus health outcomes:
those that influence provider behavior by altering the structural conditions of organization and finance or that involve the design and redesign of health care systems
those that directly target provider behavior at the individual or the group level.
Within each category, the evidence is examined to see the effect of the policy on the health outcomes of populations.
Interventions Affecting Provider Practice by Changing Structural Conditions
Although structural components such as materials and staff are not strongly linked to outcomes, other components of structure—organization and finance—can influence process by changing the socioeconomic, legal and administrative, cultural, and information context of the health care system.
Legal Mandates, Accreditation, and Administrative Regulations
Legal mandates, accreditation, and administrative regulations affect quality by controlling entry into the practice of health care. These policies include the licensing of professionals and facilities, their accreditation or certification to perform certain procedures, and the formal delineation of functions that various types of health workers can legally perform. Although these policies assume that providers' prior qualifications are good predictors of actual performance in health care delivery, there is little evidence that such policies have a positive effect on process or outcomes. They are more successful at barring unqualified persons from practicing than at ensuring quality among those who are allowed to practice. A review of health sector regulations in Tanzania and Zimbabwe, for example, revealed that the regulations primarily control entry into the market and ensure a minimum standard of quality (Kumaranayake and others 2000).
Hospital accreditation, with its periodic reviews of health facility performance standards, can potentially provide ongoing regulatory pressure for improvement. To date, research has not demonstrated that hospital accreditation programs are linked to improvements in health outcomes. In a randomized controlled trial of a hospital accreditation program in the KwaZulu-Natal province of South Africa, researchers showed a conclusive link between the implementation of the program and improvements in the accreditation standard indicators. However, they were unable to link those indicators to improvements in health outcomes (Salmon and others 2003).
Malpractice Litigation to Enforce Legal Mandates
To be effective in promoting quality, malpractice litigation must rely on adequate legal and judicial systems, which are deficient in most developing countries. In India, one of the few developing countries with the appropriate legal structure in place, inclusion of the medical sector under the Consumer Protection Act of 1986 allows victims to receive redress for negligent medical practice. Although improvements have resulted, some argue that the system needs greater involvement of professional organizations to be effective (Bhat 1996).
Peer review is as old as professional societies. The power and the influence of such societies vary widely among countries (Heaton 2000). Large provider organizations, such as hospitals or public health institutions, often routinely collect information on provider practices and patient outcomes and use those data to guide, educate, supervise, discipline, or recognize providers. In the Philippines, public health managers used a checklist of 20 observable behaviors against which health workers in remote provinces were rated. The performance of providers in facilities where workers were reviewed was significantly better than in comparable facilities that did not adopt the reviews (Loevinsohn, Guerrero, and Gregorio 1995). Others, however, assert that the "quality by inspection" environment engendered by oversight leads to an antagonistic relationship between workers and managers and precludes cooperative problem solving and continuous improvement (Berwick 1989). A qualitative study evaluating supervisor-provider interactions in health care facilities in Zimbabwe found that supervisors were adept at giving technical feedback but were not as proficient at making suggestions for improvement or at working with providers and patients to solve problems (Tavrow, Kim, and Malianga 2002).
National and Local Clinical Guidelines
In many industrial countries, evidence-based clinical guidelines are used to ensure high-quality care, better health outcomes, and cost-effective treatments. (Examples of institutions supporting this approach are the U.K. National Institute for Clinical Excellence, the U.S. Agency for Healthcare Research and Quality, and the Dutch College of General Practitioners.) Guidelines are typically developed for a clinical disease or symptom. They should be derived from evidence-based criteria resulting from well-designed clinical investigations or expert opinion. Because they are derived from empirical studies, guidelines in developing countries can, in principle, be identical to those in industrial countries. When resource constraints limit transferability, diagnostic and treatment guidelines may have to be modified. Technologies such as x-ray studies have gained widest acceptance in preventive and primary care services, such as integrated management of childhood illness, where they serve both as clinical standards and as educational guides. Including physicians in the development and review of guidelines has proved particularly effective in the challenging process of implementing guidelines.
Sharing Information on Quality Improvement Technology
Worldwide interest in quality has given rise to new professional bodies, scientific publications, and institutions dedicated to sharing ideas and innovations in quality improvement. Organizations such as the Robert Wood Johnson Foundation, the Nuffield Trust, and the Institute for Healthcare Improvement cultivate ideas for improvement, bring people and organizations together to learn from each other, and take action to achieve results. Although the sharing of information on quality health care practices has long been an established part of provider education and training networks, the sharing of information on successful systemwide policies for process improvements could potentially accelerate the scale-up of quality practice.
One organization active in developing countries is the Council on Health Research for Development (COHRED), which promotes, facilitates, and evaluates the Essential National Health Research strategy in such countries as Benin, the Arab Republic of Egypt, and Indonesia. COHRED aims to develop a system of effective health research to improve health services, including quality of care. The Quality Assurance project funded by the U.S. Agency for International Development has studied and shared information about quality in the developing world since 1990. Under the Quality Assurance project umbrella, researchers have studied and implemented quality measurement and improvement interventions and have used these case studies to develop a library of tools and articles to promote global quality improvement.
Public-Private Provision of Care
In most health care systems, a professional regulatory framework governs the network of civil servants delivering health care. These civil servants operate alongside autonomous, self-governed, private providers—independent for-profit physicians and health clinics and nonprofit nongovernmental organizations (NGOs). Two conclusions arise from the often heated debate about the right balance between public and private services. First, private practitioners provide a significant amount of care in developing countries. Second, though there is no one prescription for striking the right public-private mix, in some cases the public regulatory framework has led to private provision of higher-quality care. The government of Senegal successfully contracted with community-based groups for preventive nutrition services. Eighteen months after nutrition services were implemented, severe malnutrition disappeared among children age 6 to 11 months (Marek and others 1999). The success of the program has led to its expansion nationwide.
Targeted Education and Professional Retraining
Continuing medical education is a common approach to improving clinical practice, but it neither changes clinical practice nor advances health outcomes (Davis and others 1995). Newer techniques—targeted education, case-based learning, and interactive and multimodel teaching techniques—have had some success. In Guatemala, distance education targeting diarrhea and cholera case management increased accurate assessment and classification of diarrhea cases by 25 percent. Rehydration did not improve, however, and improvements in counseling were insignificant (Flores, Robles, and Burkhalter 2002). In Tanzania, training staff in the control of acute respiratory infections of young children yielded reductions in under-five mortality within two years (Mtango and Neuvians 1986).
In recent years, organizational change in the health care system has been shown to influence quality of care and to further the six aims of the Institute of Medicine by focusing on the continual design and redesign of systems. The emphasis is on developing organizational and individual capabilities where they most profoundly affect the process of care. Design and redesign interventions assume that simply adding a new resource or a new process in isolation will not improve care because better care is the product of many processes working together. Although change interventions have not been widely used in the developing world because they require large investments to plan and implement, four related models of organizational change have been successful in changing provider practice in developing nations:
Total Quality Management in health care Advances in business management practices to continually design and redesign systems for quality improvement have been effectively adapted for health systems. In Total Quality Management, also known as Continuous Quality Improvement, teams use mutually reinforcing techniques in a cycle of planning, implementing, evaluating, and revising to improve the quality of clinical and administrative processes. These techniques include process mapping, statistical quality control, and structured team activities. In rural Bihar, India, private practitioners who treat sick children were provided with standard case-management information, were given feedback on their performance, and were tracked and monitored over time. This strategy produced significant improvements in practitioners' case-management skills (Chakraborty, D'Souza, and Northrup 2000). In Malaysia, anesthesia safety has been improved through the implementation of consensus-based protocols that emphasize (a) communication among the operating, recovery, and ward team members; (b) individual feedback; and (c) frequent monitoring to identify areas for improvement (Tan 1999).
Collaborative Improvement Model The early success of Total Quality Management techniques has given rise to a related model, the Collaborative Improvement Model. It addresses broad and complex systemic processes within health care systems and has facilitated the scale-up of quality improvements. This model, designed to continuously improve organizational and individual performance, comprises four elements: definition of an aim, measurement, innovation, and testing to see whether the innovation meets the original aim. This approach strikes a pragmatic balance between the need for action and the need to be scientifically grounded. It has been used with success in Peru and the Russian Federation. In Peru, the collaborative improvement model was used by multidisciplinary teams in 41 clinics to design changes aimed at achieving world-class tuberculosis care. The preliminary results have led to impressive changes in the process of care, but it is too early to determine whether they have been effective in improving quality (Berwick 2004).
Plan-Do-Study-Act cycle The Plan-Do-Study-Act (PDSA) cycle calls for action-oriented learning in quality improvement. Team members using the PDSA model design a quality-improvement intervention (plan), implement it on a small scale (do), evaluate the results (study), and implement or alter the intervention accordingly (act). Often multiple PDSA cycles are necessary before the appropriate improvement method can be identified. All improvement techniques that involve the design and redesign of systems use some form of the PDSA cycle. Successful scale-up of a PDSA prototype is possible with careful leadership oversight. A team of investigators in Russia's Tula province developed a series of successful interventions for adults who have poorly controlled hypertension. The interventions, which were started in 20 clinics, were expanded to 500 clinics within 18 months. The scale-up resulted in a sevenfold increase in patients receiving hypertension management at the primary care level and an 85 percent reduction in admissions for hypertension. In Tver province, the same group addressed problems related to prenatal care. They began with 5 hospitals and scaled up to cover all 42 hospitals and all maternity clinics in the province. The result was a 99 percent reduction in newborns with hypothermia and a reduction in pregnancy-induced hypertension from 44 percent to 6 percent (Berwick 2004). Although the experience of researchers implementing interventions that are based on system redesign in the developing world has been largely positive, it is not clear whether the resources and leadership exist to bring these interventions to scale through country or regional policies. Further evidence is needed concerning the real-world feasibility and cost-effectiveness of system redesign.
Internal enabling environment Creating the right environment for change involves leadership and leadership training, clinicians empowered to make quality improvement decisions, and resources for quality improvement planning activities (Silimper and others 2002). The internal enabling environment in Costa Rica promoted strong leadership that led to the adoption of structural adjustment loans in the early stages of health sector reforms. The loans were used to maintain such public health programs as mother and child nutrition, even though public spending dropped and prices increased dramatically (Peabody 1996). An enabling environment can also be created by teams of individuals, each representing different stakeholder groups (physicians, nurses, staff members, patients, and so forth) or simply by a strong leader with an interest in teamwork and the resources to support a discrete quality improvement function for team members.
Interventions Directly Affecting Provider Practice
Practitioners are often forced to provide care in uncertain settings. Technical limitations may reduce the ability to diagnose or predict outcomes, or they may have only probabilistic knowledge about the efficacy of their proposed treatment for a particular patient. The nature of clinical practice is often solitary, and physicians have few available ways to gauge their clinical acumen and skills. Performance-based feedback, however, can reward high-quality care and increase knowledge about appropriate actions. If the feedback mechanism is effective, it can also serve as the basis for establishing systemwide incentives for improving quality of care.
Training with Peer Review Feedback
In Mexico City, physician retraining on treatment of diarrhea, combined with the concurrent creation of a peer-review structure, decreased the use of antibiotics and increased the use of oral rehydration therapy (ORT). These improvements continued to be seen in a follow-up evaluation 18 months later (Gutierrez and others 1994). The approach has been effectively expanded to prescribing practices for rhinopharyngitis among primary care physicians, using an interactive training workshop and a managerial peer-review committee (Perez-Cuevas and others 1996).
A potentially powerful instrument for accelerating quality improvements involves making payments directly to providers who meet quality standards that are based on process indicators associated with favorable patient outcomes. Systems that tie performance to remuneration use relatively small incentives—equivalent to 3 to 10 percent of the provider's total compensation. Performance-based remuneration has been successfully used in the United States to compensate both private and public providers (McBride, Neiman, and Johnson 2000).
Examples of performance-based incentives come from developing countries too. The Nicaraguan Ministry of Health has implemented a pilot program in six hospitals that offers an incentive bonus (a maximum average of 17 percent of hospital revenue) for facilities that achieve performance targets that include quality measures (Jack 2003). In Haiti, a performance-based payment scheme was set up for NGOs that provided services to the population. The scheme resulted in all three participating NGOs reaching target immunization coverage rates (Eichler, Auxila, and Pollock 2001). Thus, payment for specified and observable performance (in terms of provider effort, client coverage, or health impact on the population) can be usefully applied to NGOs and private providers.
The specific features of performance-based remuneration are crucial. A study evaluating the South African government's experience in contracting with private organizations to operate district hospitals found no cost savings—in fact, the government was spending more than if it provided the services itself. The contracting may have failed because remuneration was not based on specific process or outcome measures. Instead, the contractor's obligation, the methods of monitoring performance, and the sanctions for nonperformance were only minimally specified (Broomberg, Masobe, and Mills 1997).
High Volume of Care
Evidence exists that a high volume of care by individuals or institutions leads to better health outcomes (Habib and others 2004). Physician experience (learning) and practice (repetition) lead to fewer complications, less resource use, and better quality for a variety of procedures, such as cataract surgery and laparoscopy (Brian and Taylor 2001). More complex procedures, including endarterectomy, cancer surgery, and coronary bypass surgery, have shown similar effects.
Volume effects leading to better health outcomes are not confined to surgical procedures (Zgibor and Orchard 2004). Facilities specializing in the care of chronic diseases such as diabetes, myocardial infarction, and heart failure are also associated with better outcomes. Debate exists over how much of the volume effect is due to specialist care. The benefits of high-volume care persist, however, even after controlling for referral and case-mix biases. When carefully trained nonphysicians are substituted for physicians, volume effects persist but can be accomplished at significantly lower costs. In one study, nurse practitioners and physician's assistants were able to provide high-quality care for common outpatient conditions such as hypertension, diabetes, asthma, otitis media, pharyngitis, and back pain at substantially lower costs than that of physicians (Douglas and others 2004).
Performance-based Professional Recognition
Providers work in a community of peers in which professional status, prestige, and recognition are often as valuable as material rewards. Nonmonetary incentives, such as public recognition or disclosure, administrative privileges, and awards from professional organizations, can promote improvements in quality. Uganda, for example, implemented the Yellow Star Program as part of a broader health services improvement project. This program evaluated health facilities on a quarterly basis, using 35 indicators of technical and interpersonal quality, and awarded a large yellow star to facilities that scored 100 percent in two consecutive quarters. The star was then prominently displayed outside the facility.
The Mexican Ministry of Health has implemented a strategy that combines the accreditation and the training strategies discussed earlier with nonmonetary incentives. The National Crusade for Quality in Health Care introduces quality-oriented incentives to health facilities and medical schools. It also includes public recognition in an effort to encourage learning and to change practice. The National Crusade has already generated measurable improvements in the responsiveness of state-level health systems (Secretaria de Salud de Mexico 2003).
Both types of policies examined in this section are associated with better quality and better health outcomes—lower premature mortality and avoidable morbidity, increased patient satisfaction, and more health-seeking behaviors. When effective, these policies result in increased coverage rates, better prescribing patterns, and increased adherence to clinical guidelines. They can spell the difference between an individual's survival or death, between an individual benefiting from the encounter with the health sector or being harmed by it, and between an individual and society rising from poverty or sinking deeper into it.