Comprehensive measurement of health system performance at district level in India: Generation of a composite index.

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

[Determinants of time required by medical information technicians for quality control of hospital activity coding, in French medico-administrative system]. / Déterminants du temps nécessaire au contrôle qualité dans le cadre du programme de médicalisation des systèmes d'information (PMSI), dans le champ médecine, chirurgie et obstétrique (MCO) d'un centre hospitalier régional, par les techniciens d'information médicale.

BACKGROUND: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls. METHODS: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half. RESULTS: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10-4); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10-3). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding. CONCLUSION: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays.

Industrial perceptions of medicines regulatory harmonization in the East African Community.

BACKGROUND: Medicines regulatory harmonization has been recommended as one way to improve access to quality-assured medicines in low- and middle-income countries. The rationale is that by lowering barriers to entry more manufacturers will be enticed to enter the market, while the capacity at the national medicines regulatory authorities is strengthened. The African Medicines Regulatory Harmonization Initiative, agreed in 2009, is developing regional platforms with harmonized regulatory procedures for the registration of medicines. The first region to implement medicines regulatory harmonization was the East African Community (EAC). The harmonization was based on the existing EAC Free Trade Agreement, which officially launched the free movement of goods and services in 2010. METHODS AND FINDINGS: In this study we conducted semi-structured interviews and performed document reviews. The main target group for our interviews was pharmaceutical companies. We interviewed 18 companies, including 64% of the total companies who had experienced the EAC joint product assessment procedure, and two EAC-based national medicines regulatory authorities. We found that generally pharmaceutical companies are supportive of the African-based MRH efforts and appreciative of the progress being achieved. However, many companies are now hesitant to use the joint product assessment procedure until efficiency improvements are made. Common frustrations were the length of time to receive the actual marketing authorization; unexpectedly higher quality standards than national procedures; and challenges in getting all EAC countries to recognize EAC approvals. Smaller, less attractive markets have not yet become more attractive from a corporate perspective, and there is no free trade of pharmaceuticals in the EAC region. CONCLUSIONS: Pharmaceutical companies agree that medicines regulatory harmonization is the way forward. However, regulatory medicines harmonization must actually result in quicker access to the harmonized markets for quality-assured medicines. At this time, improvements are required to the current EAC processes to meet the vision of harmonization.

Impact of a long-term antibiotic stewardship program targeting fluoroquinolones in a French local hospital.

INTRODUCTION: Fluoroquinolones (FQs) are major antibiotics but their wide use in hospital and community settings has led to an increased bacterial resistance against this antibiotic class. We aimed to assess the efficiency of an antibiotic stewardship program targeting FQs in a local hospital, and its impact on bacterial resistance. METHODS: This observational study was conducted in the local hospital of Morteau (Franche-Comté region, East of France). The hospital has 166 beds with health and medico-social sectors and a medical home affiliated with the facility. Local guidelines on empirical treatment regimens were released in 2007 aiming to reduce the use of FQs, especially for urinary tract infections. The following monitoring indicators were assessed: total consumption of antibiotics and of FQs (DDD/1,000 hospital patient-days), and resistance to nalidixic acid among Escherichia coli strains. Changes in the number of FQ packs sold in a community pharmacy were also recorded. RESULTS: The FQ consumption decreased by 85.6% between 2006 and 2015 (from 41.1 to 5.9 DDD/1,000 patient-days). The resistance to nalidixic acid among E. coli strains substantially decreased after remaining steady until 2011 (-57.2% between 2007 and 2015). The number of norfloxacin packs sold in the assessed community pharmacy decreased by 88%. CONCLUSION: Setting up an antibiotic stewardship program in a local hospital can lead to a substantial reduction in FQ use and in E. coli resistance to FQs. It may also have a positive impact on community prescriptions.

Contextual factors and health service performance from the perspective of the provincial health administrators in Papua New Guinea.

INTRODUCTION: The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea. There are limitations in measuring performance of such projects through analysis of health information system data alone due to data quality issues and a multitude of unmeasured factors that affect performance. A mixed methods study was undertaken to understand the contextual factors that affect health service performance. METHODS: A performance assessment framework was developed including service delivery indicators derived from the National Health Information System. Prior to implementation, a baseline analysis of the indicators was undertaken. Subsequently, semi-structured interviews were conducted with health administrators, in which they were asked about factors they perceived to influence health facility performance. During the interviews, key informants were provided with health indicators for their province and asked to interpret the performance of facilities. Interviews were transcribed and inductive thematic analysis performed. RESULTS: Performance indicators varied greatly within and between districts. Key informants cited a number of reasons for this variation. Health facilities accessible by road in urban areas, with competent and/or higher level staff and health services operated by churches or private companies, were cited as contributors to high performance. For high performing districts, key informants also discussed use of health information, planning and targeted strategies to improve performance. Inadequate numbers of staff, poorly skilled staff, funding delays and challenging geography were major contributors noted for poor performance. CONCLUSION: Analysis of quantitative indicators needs to be performed at health facility level in order to understand district level performance. Interpretation of performance through key informant interviews provided useful insight into previously undocumented contextual factors affecting health delivery performance. The sequential explanatory mixed methods design could be applied to evaluations of other health service delivery programs in similar contexts.

State-based perinatal quality collaboratives: Pursuing improvements in perinatal health outcomes for all mothers and newborns.

State-based perinatal quality collaboratives (SPQC) have become increasingly widespread in the United States. Whereas the first was launched in 1997, today over 40 states have SPQCs that are actively working or are in development. Despite great variability in the structure and function of SPQCs among states, many have seen their efforts lead to significant improvements in the care of mothers and newborns. Clinical topics targeted by SPQCs have included nosocomial infection in newborns, human milk use, neonatal abstinence syndrome, early term deliveries without a medical indication, maternal hemorrhage, and maternal hypertension, among others. While each SPQC uses approaches suited to its own context, several themes are common to the goals of all SPQCs, including developing obstetric and neonatal partnerships; including families as partners; striving for participation by all providers; utilizing rigorous quality improvement science; maintaining close partnerships with public health departments; and seeking population-level improvements in health outcomes.

Neonatal outreach simulation.

Numerous factors contribute to neonatal morbidity and mortality, and inexperienced providers managing crisis situations is one major cause. Simulation-based medical education is an excellent modality to employ in community hospitals to help refine and refresh resuscitation skills of providers who infrequently encounter neonatal emergencies. Mounting evidence suggests that simulation-based education improves patient outcomes. Academic health centers have the potential to improve neonatal outcomes through collaborations with community hospital providers, sharing expertise in neonatal resuscitation and simulation. Community outreach programs using simulation have been successfully initiated in North America. Two examples of programs are described here, including the models for curricular development, required resources, limitations, and benefits. Considerations for initiating outreach simulation programs are discussed. In the future, research demonstrating improved neonatal outcomes using outreach simulation will be important for personnel conducting outreach programs. Neonatal outreach simulation is a promising educational endeavor that may ultimately prove important in decreasing neonatal morbidity and mortality.

Local Learning Collaboratives to Improve Quality for Chronic Kidney Disease (CKD): From Four Regional Practice-based Research Networks (PBRNs).

BACKGROUND: Four practice-based research networks (PBRNs) participated in a project to increase the diffusion of evidence-based treatment guidelines for chronic kidney disease (CKD). A multicomponent organizational intervention engaged regionally proximal primary care practices in a series of facilitated meetings, referred to as local learning collaboratives (LLCs). METHODS: The 2-wave strategy began with 8 practices in each PBRN receiving practice facilitation and subsequently joining an LLC. A sequential mixed-methods design addressed the conduct, content, and fidelity of the intervention; clinicians in 2 PBRNs participated in interviews, and PBRN coordinators reflected on implementation challenges. RESULTS: LLCs were formed in 3 PBRNs, with 121 monthly meetings held across 20 LLCs. Slightly more than half of the participants were clinicians. Qualitative data suggest that clinicians increased the priority for CKD care, improved knowledge and skills, were satisfied with the project, and attempted to improve care. Implementation challenges were encountered and concerns about sustainability expressed. CONCLUSION: While PBRNs can successfully leverage resources to diffuse treatment guidelines, and LLCs are well-accepted by clinical staff, the formation of LLCs was not feasible for 1 PBRN, and others struggled to meet regularly and have performance data available despite logistic support.

Care Appropriateness and Health Productivity Evolution: A Non-Parametric Analysis of the Italian Regional Health Systems.

BACKGROUND: There has been increasing interest in measuring the productive performance of healthcare services since the mid-1980s. OBJECTIVE: By applying bootstrapped data envelopment analysis across the 20 Italian Regional Health Systems (RHSs) for the period 2008-2012, we employed a two-stage procedure to investigate the relationship between care appropriateness and productivity evolution in public hospital services. METHODS: In the first stage, we estimated the Malmquist index and decomposed this overall measure of productivity into efficiency and technological change. In the second stage, the two components of the Malmquist index were regressed on a set of variables measuring per capita health expenditure, care appropriateness, and clinical appropriateness. RESULTS: Malmquist analysis shows that no gains in productivity in the health industry have been achieved in Italy despite the sequence of reforms that took place during the 1990s, which were devoted to increasing efficiency and reducing costs. Analysis of the efficiency change index clearly indicates that the source of productivity gain relies on a rationalization of the employed inputs in the Italian RHSs. At the same time, the trend of the technological change index reveals that the health systems in the three macro-areas (North, Central, and South) are characterized by technological regress. CONCLUSION: Overall, our results suggest that productivity increases could be achieved in the Italian health system by reducing the level of inputs, improving care and clinical appropriateness, and by counteracting the 'DRG (diagnosis-related group) creep' phenomenon.

Use of Balanced Scorecard Methodology for Performance Measurement of the Health Extension Program in Ethiopia.

In 2004, Ethiopia introduced a community-based Health Extension Program to deliver basic and essential health services. We developed a comprehensive performance scoring methodology to assess the performance of the program. A balanced scorecard with six domains and 32 indicators was developed. Data collected from 1,014 service providers, 433 health facilities, and 10,068 community members sampled from 298 villages were used to generate weighted national, regional, and agroecological zone scores for each indicator. The national median indicator scores ranged from 37% to 98% with poor performance in commodity availability, workforce motivation, referral linkage, infection prevention, and quality of care. Indicator scores showed significant difference by region (P < 0.001). Regional performance varied across indicators suggesting that each region had specific areas of strength and deficiency, with Tigray and the Southern Nations, Nationalities and Peoples Region being the best performers while the mainly pastoral regions of Gambela, Afar, and Benishangul-Gumuz were the worst. The findings of this study suggest the need for strategies aimed at improving specific elements of the program and its performance in specific regions to achieve quality and equitable health services.

Education, exposure and experience of prehospital teams as quality indicators in regional trauma systems.

OBJECTIVE: Indicators to measure the quality of trauma care may be instrumental in benchmarking and improving trauma systems. This retrospective, observational study investigated whether data on three indicators for competencies of Dutch trauma teams (i.e. education, exposure, experience; agreed upon during a prior Delphi procedure) can be retrieved from existing registrations. The validity and distinctive power of these indicators were explored by analysing available data in four regions. METHODS: Data of all polytrauma patients treated by the Helicopter Emergency Medical Services were collected retrospectively over a 1-year period. During the Delphi procedure, a polytrauma patient was defined as one with a Glasgow Coma Scale of 9 or less or a Paediatric Coma Scale of 9 or less, together with a Revised Trauma Score of 10 or less. Information on education, exposure and experience of the Helicopter Emergency Medical Services physician and nurse were registered for each patient contact. RESULTS: Data on 442 polytrauma patients could be retrieved. Of these, according to the Delphi consensus, 220 were treated by a fully competent team (i.e. both the physician and the nurse fulfilled the three indicators for competency) and 22 patients were treated by a team not fulfilling all three indicators for competency. Across the four regions, patients were treated by teams with significant differences in competencies (P=0.002). CONCLUSION: The quality indicators of education, exposure and experience of prehospital physicians and nurses can be measured reliably, have a high level of usability and have distinctive power.

Shooting for Safety.

Austin Regional Clinic announced in June that it would no longer accept new pediatric patients whose parents or guardians don't permit vaccinations. The new policy aims to protect the clinic's most vulnerable patients, such as infants who aren't fully vaccinated, seniors, those who have compromised immune systems, and pregnant women. An exception is included for patients who have adverse reactions to vaccines or severely compromised immune systems.

[Chronic obstructive lung disease management programmes do not benefit the coordination of care pathways].

Chronic obstructive lung disease (COLD) is a challenging condition for both primary and secondary health-care providers. Disease management programmes (DMP's) have been expected to lead to evident improvements in the continuum of care for COLD. The utility of a COLD management programme was evaluated in a study based on interviews among general practitioners and COLD specialists. Clinicians preferred short practical guidelines to the DMP. The DMP was found useless as a tool to improve the coordination of care pathways. Complimentary interventions to improve clinical cooperation across sectors are recommended.

The Italian institutional accreditation model for Haemophilia Centres.

BACKGROUND: In Italy, basic health needs of patients with inherited bleeding disorders are met by a network of 50 haemophilia centres belonging to the Italian Association of Haemophilia Centres. Further emerging needs, due to the increased life expectancy of this patient group, require a multi-professional clinical management of the disease and provide a challenge to the organisation of centres.In order to achieve harmonised quality standards of haemophilia care across Italian Regions, an institutional accreditation model for haemophilia centres has been developed. MATERIAL AND METHODS: To develop an accreditation scheme for haemophilia centres, a panel of experts representing medical and patient bodies, the Ministry of Health and Regional Health Authorities has been appointed by the National Blood Centre. Following a public consultation, a technical proposal in the form of recommendations for Regional Health Authorities has been formally submitted to the Ministry of Health and has formed the basis for a proposal of Agreement between the Government and the Regions. RESULTS: The institutional accreditation model for Haemophilia Centres was approved as an Agreement between the Government and the Regions in March 2013. It identified 23 organisational requirements for haemophilia centres covering different areas and activities. DISCUSSION: The Italian institutional accreditation model aims to achieve harmonised quality standards across Regions and to implement continuous improvement efforts, certified by regional inspection systems. The identified requirements are considered as necessary and appropriate in order to provide haemophilia services as "basic healthcare levels" under the umbrella of the National Health Service. This model provides Regions with a flexible institutional accreditation scheme that can be potentially extended to other rare diseases.

Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana.

BACKGROUND: Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP 'works' when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. METHODS: We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. RESULTS: The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP's underlying goal of organisational control. CONCLUSIONS: Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.