How to prioritise in quality improvement? Targeted implementation as a key for quality improvement in Kenyan health facilities.

BACKGROUND: Data from national surveys of low- and middle income countries indicates that there is still a need to improve the quality of healthcare in resource-poor settings. This study aims to understand the benefit of an integral, facility-driven, indicator-based approach used as a decision-making tool to define effective quality improvement interventions in Kenya. OBJECTIVE: The aim of the study is to understand whether the integral approach developed leads to effective interventions. METHODS: Categorical data is collected from ten health facilities covered by the Integrated Quality Management System (IQMS) project in Kenya. First the information on concrete improvement interventions implemented within the facilities is collected and merged into five different intervention topics. Second, groups of facilities with similar quality improvement interventions are selected to compare between the first and second quality assessment rounds. Those IQMS indicators matching the content of the intervention topic are extracted from the software VISOTOOL. In a third step, the data is summarised using means and SD. A one sample T-test is applied on the mean changes and SD. Frequency counts and percentages were used for the presentation of categorical data. RESULTS: All improvement interventions resulted in positive and higher change values (T2-T1). Four of five intervention topics, show statistically significant improvements including neonatal mortality (42%; p<0.0001), waiting time (39%; p=0.0490), infection prevention control (28%; p=0.0007) and with shortages of staffing and transport in remote areas (32%; p=0.0194). CONCLUSIONS: In all facilities the interventions selected have a positive impact, some of which markedly improved. It demonstrates that this integral quality improvement approach in Kenya can serve as an effective decision-making tool for identification and prioritisation of interventions. Those targeted interventions, being performed under institutionalisation in form of coaching and tutoring, effectively contribute to improving the quality of care in resource poor settings.

Is patient loyalty associated with quality of care? Results of a patient survey over primary care in Switzerland.

OBJECTIVE: The study aimed to evaluate quality of care and to determine which aspects are associated with the willingness to recommend the general practitioner (GP) as a part of patient loyalty. DESIGN: This was an exploratory study which collected patient data from ambulatory care in the German part of Switzerland between 2013 and 2016. SETTING: Primary care in Switzerland. PARTICIPANTS: Included patients from 79 primary care practices who volunteered to participate in the quality management system European Practice Assessment. Patients were afterwards asked to complete the European Task Force on Patient Evaluations of General Practice Care instrument. INTERVENTIONS: Describing influencing factors of quality of care on recommendation of the GP from the perspective of the patients. MAIN OUTCOME MEASURES: Patient perspective on quality of care. RESULTS: Survey respondent rate was 81.3%. Over 69% of the respondents were willing to recommend their GP. 'Listening to you' (94.2%) and 'interest in your personal situation' (93.0%) as a part of the domain 'relationship and communication' were rated as the highest quality criteria. The lowest rate was found for 'being able to speak to the GP on the telephone' (30.0%) and 'waiting time in the waiting room' (50.6%). Patient loyalty, in terms of willingness to recommend the GP, was strongly associated with most of the items under the 'relationship and communication' section but also with having more physician's assistants in the practice. CONCLUSIONS: The results are important for understanding patients' priorities with regard to general practice care. Patient assessment allows us to identify possible areas for quality improvement within the practice and could provide feedback.

If you can't measure it- you can't change it - a longitudinal study on improving quality of care in hospitals and health centers in rural Kenya.

BACKGROUND: The Kenyan Ministry of Health- Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end an integrated quality management system based on validated indicators derived from the Kenya Quality Model for Health (KQMH) was developed and adapted to the area of Reproductive and Maternal and Neonatal Health, implemented and analysed. METHODS: An integrated quality management (QM) approach was developed based on European Practice Assessment (EPA) modified to the Kenyan context. It relies on a multi-perspective, multifaceted and repeated indicator based assessment, covering the 6 World Health Organization (WHO) building blocks. The adaptation process made use of a ten step modified RAND/UCLA appropriateness Method. To measure the 303 structure, process, outcome indicators five data collection tools were developed: surveys for patients and staff, a self-assessment, facilitator assessment, a manager interview guide. The assessment process was supported by a specially developed software (VISOTOOL®) that allows detailed feedback to facility staff, benchmarking and facilitates improvement plans. A longitudinal study design was used with 10 facilities (6 hospitals; 4 Health centers) selected out of 36 applications. Data was summarized using means and standard deviations (SDs). Categorical data was presented as frequency counts and percentages. RESULTS: A baseline assessment (T1) was carried out, a reassessment (T2) after 1.5 years. Results from the first and second assessment after a relatively short period of 1.5 years of improvement activities are striking, in particular in the domain 'Quality and Safety' (20.02%; p < 0.0001) with the dimensions: use of clinical guidelines (34,18%; p < 0.0336); Infection control (23,61%; p < 0.0001). Marked improvements were found in the domains 'Clinical Care' (10.08%; p = 0.0108), 'Management' (13.10%: p < 0.0001), 'Interface In/out-patients' (13.87%; p = 0.0246), and in total (14.64%; p < 0.0001). Exemplarily drilling down the domain 'clinical care' significant improvements were observed in the dimensions 'Antenatal care' (26.84%; p = 0.0059) and 'Survivors of gender-based violence' (11.20%; p = 0.0092). The least marked changes or even a -not significant- decline of some was found in the dimensions 'delivery' and 'postnatal care'. CONCLUSIONS: This comprehensive quality improvement approach breathes life into the process of collecting data for indicators and creates ownership among users and providers of health services. It offers a reflection on the relevance of evidence-based quality improvement for health system strengthening and has the potential to lay a solid ground for further certification and accreditation.

Quality management: where is the evidence? Developing an indicator-based approach in Kenya.

INTRODUCTION: The 2030 Sustainable Development Agenda emphasizes the importance of quality of care in the drive to achieve universal health coverage. Despite recent progress, challenges in service delivery, efficiency and resource utilization in the health sector remain. OBJECTIVE: The Ministry of Health Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end, the European Practice Assessment (EPA) was adapted to the area of Reproductive and Maternal and Neonatal Health. METHODS: The adaptation process made use of a ten step-modified RAND Corporation/University of California Los Angeles (UCLA) Appropriateness Method. The steps included a scoping workshop, definition of five critical domains of quality in the Kenyan context ('People, Management, Clinical Care, Quality & Safety, Interface between inpatients and outpatients care'), a review of policy documents, management and clinical guidelines, grey and scientific literature to identify indicators in use in the Kenyan health system and an expert panel process to rate their feasibility and validity. RESULTS: The resulting 278 indicators, clustered across the five domains, were broken-down into 29 dimensions and assigned measure specifications. A set of data collection tools were developed to furnish the indicators and piloted at two health facilities. They were subsequently finalized for use in 30 health facilities in 3 counties. CONCLUSIONS: The integrative and indicator-based aspects of the EPA process could be readily adapted to facilitate the operationalization of a practical quality assurance approach in Kenya.

[Integrated Quality Management System (IQMS): a model for improving the quality of reproductive health care in rural Kenya]. / Integrated Quality Management System (IQMS): ein Modell zur Förderung der Qualität der reproduktiven Gesundheitsversorgung im ländlichen Kenia.

OBJECTIVES: To develop a model aiming to improve the quality of services for reproductive health care in rural Kenya and designed to measure the quality of reproductive health services in such a way that allows these services to identify measures for improving their performance. METHODS: The Integrated Quality Management System (IQMS) was developed on the basis of a pre-existing and validated model for quality promotion, namely the European Practice Assessment (EPA). The methodology for quality assessment and feedback of assessment results to the service teams was adopted from the EPA model. Quality assessment methodology included data assessment through staff, patient surveys and service visitation. Quality is assessed by indicators, and so indicators had to be developed that were appropriate for assessing reproductive health care in rural Kenya. A search of the Kenyan and international literature was conducted to identify potential indicators. These were then rated for their relevance and clarity by a panel of Kenyan experts. RESULTS: 260 indicators were rated as relevant and assigned to 29 quality dimensions and 5 domains. The implementation of IQMS in ten facilities showed that IQMS is a feasible model for assessing the quality of reproductive health services in rural Kenya. IQMS enables these services to identify quality improvement targets and necessary improvement measures. Both strengths and limitations of IQMS will be discussed.

Working Atmosphere and Job Satisfaction of Health Care Staff in Kenya: An Exploratory Study.

BACKGROUND: Job satisfaction and working atmosphere are important for optimal health care delivery. The study aimed to document working atmosphere and job satisfaction of health care professionals in Kenya and to explore associations between job satisfaction, staff characteristics, and working atmosphere. METHODS: Data from the integrated quality management system (IQMS) for the health sector in Kenya were used. Job satisfaction was measured with 10 items and with additional 5 items adapted to job situation in Kenya. Working atmosphere was measured with 13 item questionnaire. A stepwise linear regression analysis was performed with overall job satisfaction and working atmosphere, aspects of job satisfaction, and individual characteristics. RESULTS: Out of 832 questionnaires handed out, 435 questionnaires were completed (response rate: 52.3%). Health care staff indicated high commitment to provide quality services and low levels regarding the adequacy and functionality of equipment at their work station. The aspect "support of the ministry of health" (ß = 0.577) showed the highest score of explained variance (32.9%) regarding overall job satisfaction. CONCLUSIONS: IQMS which also evaluates job satisfaction and working atmosphere of health care staff provides a good opportunity for strengthening the recruitment and retention of health care staff as well as improving the provision of good quality of care.

Does a quality management system improve quality in primary care practices in Switzerland? A longitudinal study.

OBJECTIVES: To examine the effectiveness of the quality management programme--European Practice Assessment--in primary care in Switzerland. DESIGN: Longitudinal study with three points of measurement. SETTING: Primary care practices in Switzerland. PARTICIPANTS: In total, 45 of 91 primary care practices completed European Practice Assessment three times. OUTCOMES: The interval between each assessment was around 36 months. A variance analyses for repeated measurements were performed for all 129 quality indicators from the domains: 'infrastructure', 'information', 'finance', and 'quality and safety' to examine changes over time. RESULTS: Significant improvements were found in three of four domains: 'quality and safety' (F=22.81, p<0.01), 'information' (F=27.901, p<0.01) and 'finance' (F=4.073, p<0.02). The 129 quality indicators showed a significant improvement within the three points of measurement (F=33.864, p<0.01). CONCLUSIONS: The European Practice Assessment for primary care practices thus provides a functioning quality management programme, focusing on the sustainable improvement of structural and organisational aspects to promote high quality of primary care. The implementation of a quality management system which also includes a continuous improvement process would give added value to provide good care.

Effectiveness of a quality management program in dental care practices.

BACKGROUND: Structured quality management is an important aspect for improving patient dental care outcomes, but reliable evidence to validate effects is lacking. We aimed to examine the effectiveness of a quality management program in primary dental care settings in Germany. METHODS: This was an exploratory study with a before-after-design. 45 dental care practices that had completed the European Practice Assessment (EPA) accreditation scheme twice (intervention group) were selected for the study. The mean interval between the before and after assessment was 36 months. The comparison group comprised of 56 dental practices that had undergone their first assessment simultaneously with follow-up assessment in the intervention group. Aggregated scores for five EPA domains: 'infrastructure', 'information', 'finance', 'quality and safety' and 'people' were calculated. RESULTS: In the intervention group, small non-significant improvements were found in the EPA domains. At follow-up, the intervention group had higher scores on EPA domains as compared with the comparison group (range of differences was 4.2 to 10.8 across domains). These differences were all significant in regression analyses, which controlled for relevant dental practice characteristics. CONCLUSIONS: Dental care practices that implemented a quality management program had better organizational quality in contrast to a comparison group. This may reflect both improvements in the intervention group and a selection effect of dental practices volunteering for the first round of EPA practice assessment.

Job satisfaction of practice assistants in general practice in Germany: an observational study.

BACKGROUND: Job satisfaction of practice staff is important for optimal health care delivery and for minimizing the turnover of non-medical professions. OBJECTIVE: To document the job satisfaction of practice assistants in German general practice and to explore associations between job satisfaction, staff characteristics and culture in general practice organizations. METHODS: The study was based on data from the European Practice Assessment accreditation scheme for general practices and used an observational design. The study population consisted of 1158 practice assistants from 345 general practices across Germany. Job satisfaction was measured with the 10-item Warr-Cook-Wall questionnaire. Organizational culture was evaluated with four items. A linear regression analysis was performed in which each of the job satisfaction items was handled as dependent variable. RESULTS: Out of 1716 staff member questionnaires handed out to practice assistants, 1158 questionnaires were completed (response rate: 67.5%). Practice assistants were most satisfied with their colleagues and least satisfied with their income. Higher job satisfaction was associated with issues of organizational culture, particularly a good working atmosphere, opportunities to suggest and influence areas for improvement and clear responsibilities within the practice team. CONCLUSIONS: Prioritizing initiatives to maintain high levels of, or to improve the job satisfaction of practice assistants, is important for recruitment and retention. It will also help to improve working conditions for both practice assistants and GPs and create an environment to provide better quality care.

Evaluation of patient perspective on quality of oral health care in Germany--an exploratory study.

BACKGROUND: Patients' evaluation of care presents an essential dimension of the quality of care. The aim of this exploratory study was to determine which factors of EUROPEP-Dental were associated with overall patients' evaluation of oral health care. METHODS: Data were collected from 8,160 patients from 106 dental practices (response rate 77%) who completed the 30-item EUROPEP-Dental questionnaire. The possible answers ranged from 1 (poor) to 5 (excellent). The EUROPEP-Dental questionnaire covers four domains: 'dentist-patient relationship' (11 items), 'accessibility and waiting time' (10 items), 'quality of care' (six items), 'costs of care' (three items). Each domain was aggregated by mean scores of the associated items. Regression analyses were performed in addition to descriptive analyses. RESULTS: Over 66% of the patients were overall positive with their dental care. Linear regression analyses were performed with patient satisfaction as the dependent outcome variable. The item 'medical-technical quality of care' showed the highest score (R2 = 0.378) of explained variance, while the EUROPEP-Dental domain 'quality of care' showed the highest score (R2 = 0.467) for explained variance regarding overall patient satisfaction. CONCLUSIONS: The results are important for understanding patients' priorities with regard to oral health care and for identifying possible areas for improvement of quality. The evaluation of patient perspective on quality of oral health care is likely to continue to be an important aspect of oral health-care evaluation.

[Benchmarking in ambulatory care practices--The European Practice Assessment (EPA)]. / Benchmarking in der ambulanten Versorgung am Beispiel des Europäischen Praxisassessments (EPA).

The European Practice Assessment (EPA) is a comprehensive quality management which consists of 220 indicators covering 5 domains (infrastructure, people, information, finance, and quality and safety). The aim of the project presented was to evaluate EPA as an instrument for benchmarking in ambulatory care practices. A before-and-after design with a comparison group was chosen. One hundred and two practices conducted EPA at baseline (t1) and at the 3-year follow-up (t2). A further 209 practices began EPA at t2 (comparison group). Since both practice groups differed in several variables (age of GP, location and size of practice), a matched-pair design based on propensity scores was applied leading to a subgroup of 102 comparable practices (out of the 209 practices). Data analysis was carried out using Z scores of the EPA domains. The results showed significant improvements in all domains between t1 and t2 as well as between the comparison group and t2. Furthermore, the results demonstrate that the implementation of total quality management and the re-assessment of the EPA procedure can lead to significant improvements in almost all domains.