Breaking barriers: assessing the impact of clinical quality improvements on reducing health disparities in hypertension care among Mumbai's urban slums.

The clinical quality improvement initiatives, led by the organisation's Health Equity Working Group (HEWG), aim to support healthcare providers to provide equitable, quality hypertension care worldwide. After coordinating with the India team, we started monitoring the deidentified patient data collected through electronic health records between January and May 2021. After stratifying data by age, sex and residence location, the team found an average of 55.94% of our hypertensive patients control their blood pressure, with an inequity of 11.91% between male and female patients.The objective of this study was to assess the effectiveness of using clinical quality improvement to improve hypertension care in the limited-resourced, mobile healthcare setting in Mumbai slums. We used the model for improvement, developed by Associates in Process Improvement. After 9-month Plan-Do-Study-Act (PDSA) cycles, the average hypertensive patients with controlled blood pressure improved from 55.94% to 89.86% at the endpoint of the initiative. The gender gap reduced significantly from 11.91% to 2.19%. We continued to monitor the blood pressure and found that the average hypertensive patients with controlled blood pressure remained stable at 89.23% and the gender gap slightly increased to 3.14%. Hypertensive patients have 6.43 times higher chance of having controlled blood pressure compared with the preintervention after the 9-month intervention (p<0.001).This paper discusses the efforts to improve hypertension care and reduce health inequities in Mumbai's urban slums. We highlighted the methods used to identify and bridge health inequity gaps and the testing of PDSA cycles to improve care quality and reduce disparities. Our findings have shown that clinical quality improvement initiatives and the PDSA cycle can successfully improve health outcomes and decrease gender disparity in the limited-resource setting.

Assessing the Feasibility and Effects of Introducing the USA National Surgical Quality Improvement Program on Clinical Outcomes and Cost in Saudi Arabia: An Observational Study.

Introduction: This study aimed at introducing a systematic clinical registry to assess the outcomes of surgical performances and the associated costs of surgical complications in hospitals of Saudi Arabia. Materials and Methods: This was an observational retrospective cohort study. Three large Saudi public hospitals from different regions participated in the study. A systematic sample consisting of 2077 medical records was retrospectively reviewed after being received from the hospitals' surgical wards. The inclusion criteria of the study were inpatients of the surgical cases, patients older than 18 years, and those who underwent major surgery under general anesthesia. The occurrence of adverse events in surgical wards and the direct costs associated with these surgical adverse events were estimated. Results were reported in terms of odds ratio and 95% confidence interval. A value of p < 0.05 was considered statistically significant. Results: Introducing the systematic clinical registry to assess surgical outcomes and complications across multiple hospital sites is feasible. The findings of the study suggest that some areas are exemplary and others need improvement, such as sepsis cases, renal failure, ventilator use for more than 48 h, urinary tract infection, surgical site infection (SSI), length of stay after colorectal surgery, and rehospitalization. Additional costs from surgical complications in Riyadh only were approximately 0.5 million Saudi Arabian Riyal (127,764.40 USD) during that year. Most of the additional costs were due to sepsis and SSI. Conclusion: Empirical evidence derived from the idea of introducing a National Surgical Quality Improvement Program might be generally applicable to other countries in the region and worldwide, and can be used to measure surgical adverse events and track interventions over time. As a result, quality improvement initiatives could be identified to be implemented immediately focusing on preventing several surgical adverse events. A future study is needed to explore the underlying factors that contribute to the occurrence of surgical adverse events to be prevented and/or mitigated.

Are the SDGs leaving safer surgical systems behind?

The World Health Organisation (WHO) has set out its new aims for the post-2015 global agenda in the form of the Sustainable Development Goals (SDGs). Discussions around the historically neglected role of emergency and essential surgical interventions in global health has attracted widespread attention with the help of well-timed, high-profile reports including the Lancet Commission for Global Surgery [1]. The case for promoting safe surgery is clear with evidence suggesting that at least two-thirds of the years of life lost globally will be attributed to surgical conditions by 2025 [1]. In 2010 alone, almost 17 million lives, and more than 70 million disability-adjusted life years (DALYs) were lost due to surgically treatable conditions [1]. A central component of the SDGs is its renewed focus on health as a human right in the form of Universal Health Coverage (UHC). However, there are doubts as to how nations will be able to keep the 'promise of leaving no-one behind' without explicit reference to global surgery within the SDG framework [2].

The Global Trigger Tool shows that one out of seven patients suffers harm in Palestinian hospitals: challenges for launching a strategic safety plan.

OBJECTIVE: The aim of this study was to evaluate patient safety levels in Palestinian hospitals and to provide guidance for policymakers involved in safety improvement efforts. DESIGN: Retrospective review of hospitalized patient records using the Global Trigger Tool. SETTING: Two large hospitals in Palestine: a referral teaching hospital and a nonprofit, non-governmental hospital. PARTICIPANTS: A total of 640 random records of discharged patients were reviewed by experienced nurses and physicians from the selected hospitals. INTERVENTION: Assessment of adverse events. MAIN OUTCOME MEASURES: Prevalence of adverse events, their preventability and harm category. Descriptive statistics and Cohen kappa coefficients were calculated. RESULTS: One out of seven patients (91 [14.2%]) suffered harm. Fifty-four (59.3%) of these events were preventable; 64 (70.4%) resulted in temporary harm, requiring prolonged hospitalization. Good reliability was achieved among the independent reviewers in identifying adverse events. The Global Trigger Tool showed that adverse events in Palestinian hospitals likely occur at a rate of 20 times higher than previously reported. Although reviewers reported that detecting adverse events was feasible, we identified conditions suggesting that the tool may be challenging to use in daily practice. CONCLUSION: One out of seven patients suffers harm in Palestinian hospitals. Compromised safety represents serious problems for patients, hospitals and governments and should be a high priority public health issue. We argue that direct interventions should be launched immediately to improve safety. Additional costs associated with combating adverse events should be taken into consideration, especially in regions with limited resources, as in Palestine.

The evaluation of quality assurance: developing and testing practical methods for managers.

OBJECTIVE OF THE STUDY: To develop an approach for evaluating quality assurance (QA) activities and programs in health care settings and to test different evaluation methods. DESIGN: This was not a formal scientific study, but rather a research and development (R&D) study, which followed the following steps: (1) reviewing the literature; (2) clarifying critical issues for all key aspects of QA activities; (3) drafting a guide to provide a flexible vehicle for different approaches; (4) testing and adapting the guide as it evolved in three countries; and (5) testing two evaluation tools (self-assessment and appreciative evaluation) in Chile. SETTING AND STUDY PARTICIPANTS: The evaluation guide was tested by evaluating QA structures, activities, and programs at the country, regional, and facility levels in Zambia, Niger, and Chile. RESULTS: The study resulted in an evaluation guide, which includes an implementation outline, an evaluation matrix, and an appendix of evaluation tools and methods. The guide helps evaluators: agree on a proposed evaluation's scope and design; develop an evaluation methods plan; and address QA history, advocacy, culture, and structure, as well as QA activities and accomplishments. Specific results of the country evaluations in Zambia, Niger, and Chile are presented in separate articles in this supplement. CONCLUSION: The QA programs in which the evaluation guide was tested differed in many ways, such as health system structure, decision to focus on particular services, political level implementing QA, policy environment, leadership, and program evolution. The implementation guide presents an outline of the key implementation steps for an evaluation, and includes checklists and model forms (e.g. sample agenda for a team planning meeting, sample list of questions to focus the evaluation). The evaluation matrix presents indicators by QA component and key question, and it enables evaluators to build an approach and select methods. The appendix describes the various tools and methods presented in the first two sections of the evaluation guide.

The Chilean legacies in health care quality.

OBJECTIVE: The Chilean quality assurance (QA) program evaluation took place in July 1999, at the request of the Chilean Ministry of Health. The main objectives of the evaluation were to identify key aspects of the 8-year-old Chilean QA program that could be considered by other countries and to make strategic recommendations. SETTING: In 1991, the Ministry of Health of Chile launched a national QA program. A national-level team initiated countrywide training of health care providers in QA skills, the development of quality committees at facility levels to direct local quality improvement activities, and training of quality monitors to provide technical support for training and quality improvement activities. DESIGN: The evaluation team, consisting of two international consultants and a regional consultant from the Costa Rican Ministry of Health, visited six regions and seven health 'servicios' (geographically defined administrative units within a region). The regions and servicios were purposefully chosen to represent different geographic areas, types of facilities, and levels of performance of QA activities. The evaluation was based on a framework developed and applied by the Quality Assurance Project (Center for Human Services, USA). Group and individual interviews with staff complemented document and record reviews. RESULTS: The evaluation team found that Chile's QA program had been successful in achieving sustainability and institutionalization. Factors contributing to this success included the enabling environment, management and leadership, technical functions, and support functions. CONCLUSION: The Chilean QA program constitutes an interesting experience for consideration by other countries. Key features include its sustainability, nationwide coverage, decentralization, and alliance of quality improvement and regulation. Training results are impressive: almost 20% of Ministry of Health personnel received training, and 19 training modules are in use. Coaches are active and technically sustaining quality assurance activities nationwide.