Comparative validity of three methods for assessment of the quality of primary health care.

OBJECTIVE: This study compared the sensitivity and specificity of three assessment methods to detect the performance of key clinical tasks by health workers in a primary care setting. DESIGN: Health worker performance during patient encounters for acute respiratory infections, acute diarrhea and family planning counseling was assessed through checklist-based observation of the consultation, interview with the mother following the consultation, and review of the patient's clinical record. The results of each method regarding the performance of key tasks by health workers were compared to a 'gold standard', defined as the application of the observation checklist by observers with extensive quality assessment experience. Patient encounters were studied in three Ministry of Health facilities in the Department of Totonicapán, Guatemala, involving care by physicians, nurses and auxiliary staff RESULTS: The three methods showed reasonably high levels of sensitivity (generally about 70%) for the detection of failures in the performance of most health worker tasks. The greatest problem experienced by each method related to specificity, i.e. capacity to recognize quality successes and only detect real failures. CONCLUSION: Direct observation demonstrated the best overall balance of sensitivity and specificity. Exit interview of the mother demonstrated good sensitivity and better specificity than record review.

Quality assurance in transition.

This paper outlines the early approaches to quality assurance, and its transition from business to health care. It then describes the development of the more recent trends in quality assurance of Total Quality Management and Continuous Quality Improvement and discusses the strengths and weaknesses of these approaches. The paper then goes on to show how these approaches have been modified for application to peripheral health services in developing countries through the work of the Primary Health Care Operations Research Project and the Quality Assurance Project.

PIP: Continuous Quality Improvement (CQI) will, with time and patience, eventually become operational in most organizations, but developing countries must begin by establishing quality improvements at the primary level, and not at the periphery. Quality of care means, for instance, averting infection the first time around by maintaining sterile conditions, and not using unnecessary antibiotics. Quality of care becomes an important issue as services become more costly to the user, and as the world moves toward democratization and focusing on the rights of the client to effective, affordable care. Quality of care is the provision of services that maximize patient health status and personal satisfaction and minimize cost. Quality assurances can be traced back over 2000 years, to when Chinese physicians were tested on their knowledge. Most quality assurance has focused on outcomes of care and rarely on internal organization; outpatient care has been neglected. During the 1980s, there was an increased interest generated in Total Quality Management and CQI. The US established the National Demonstration Project on Quality Improvement in Health Care among 21 Health Maintenance Organizations and hospitals. The project concluded that flow charts, cause-effect diagrams, and control charts were useful devices for resolving health care service problems, and that CQI required the creation of process teams for solving cross-functional problems. CQI tools could be used with existing data and were particularly useful when time of day was included. Hospital staff enjoyed using analytic tools for problem analysis and problem solving. Physicians were uncooperative, but nurses participated enthusiastically in process improvement teams. CQI tools were found to be simple to use. Adaptation of CQI for developing countries resulted in the preparation of a Primary Health Care Thesaurus with job performance standards. Common problems found in evaluations were failure of health workers to communicate effectively with mothers of children, and weak supervision.