QA: Background Literature & Case Studies

This group contains a section for papers that are especially suitable for developing countries, a section for papers relevant to both developed and developing country health services, a section for background about the evolving U.S. public health accreditation system, a section with review articles concerning the evidence for effectiveness of various QA approaches, several references that relate to the choice of indicators for cancer control programs (since the Cancer Council of the Pacific Islands has a particular interest in whole system QA programs that also improve cancer programs in the jurisdictions), and a listing of international QA-related journals.

A Primer for Quality Assurance in Pacific Island Health Services

Durand, AM Key Reference

A discussion of considerations for selecting appropriate models of quality assurance programs based on the current local health services situation.

A Primer for Quality Assurance in Pacific Island Health Services

Quality Improvement and the Hierarchy of Needs in Low Resource Settings - Perspective of a District Health Officer

Durand, AM Key Reference

A discussion of the importance of basic, broad-based quality improvement approaches for making health services in developing countries more managable. Based on the writer’s experience as a district health officer in Yap in the Federated States of Micronesia.

Quality Improvement and the Hierarchy of Needs in Low Resource Settings

Quality and Accreditation in Health Care Services, a Global Review

Shaw C., 2003 (225 pgs). Key Reference

Review conducted by the International Society for Quality in Health Care under contract to the World Health Organization. The first of this report’s three parts describes structures and activities at national and international levels around the world (especially in developing countries) to promote quality in health care. The second part catalogues quality concepts and tools in local use in various countries. The third part outlines initiatives in health service accreditation and analyses the operation of functioning national programs around the world. The appendices include recommendations of major international bodies and meetings on quality assurance. This is a thorough introduction. The recommendations appendix gives a good summary of lessons learned by participants in these conferences.

http://www.who.int/hrh/documents/en/quality_accreditation.pdf

A Framework for Institutionalizing Quality Assurance

Silimperi D., et. al. International Journal for Quality in Health Care 2002; Vol 14, Suppl 1: 67–73 Key Reference

Provides a framework and “road map” for introducing quality assurance initiatives into a health care organization. Addresses preconditions for readiness for QA within a health organization, the process of implementation through stages of developing awareness, experience on a limited scale, program expansion and consolidation. Discusses considerations for assuring sustainability. Excellent background material for deciding how best to plan, attain, and maintain a QA program.

http://intqhc.oxfordjournals.org/cgi/reprint/14/suppl_1/67

A more comprehensive version of the same material was published as a monograph:

Sustaining Quality of Healthcare: Institutionalization of Quality Assurance

Franco LM, et. al. 2002 QA Monograph Series.

Published for the U.S.Agency for International Development (USAID) by the Quality Assurance Project

Institutionalization of Quality Assurance

Lessons from Developing Nations on Improving Health Care

Berwick D. British Medical Journal 2004; 328; 1124-29. Key Reference

A summary of barriers, keys to success and lessons learned by one of the leaders in the field of quality improvement in health care in developing countries. Berwick advocates setting bold but practical goals, emphasizing teams as the unit of intervention, and keeping measurement processes simple.

http://www.bmj.com/cgi/reprint/328/7448/1124

Managing Programs to Maximize Access and Quality: Lessons Learned from the Field

MAQ Paper Vol. 1, No 3, pgs 1-15, 2000.

A summary of insights gleaned from an on-line forum of program managers and funders working in reproductive health and child survival programs. Many of their insights apply equally well to more general quality assurance programs.

http://www.maqweb.org/maqdoc/vol3.pdf

Licensure, Accreditation, and Certification: Approaches to Health Services Quality

Anne L. Rooney, R.N., M.S., M.P.H. Paul R. van Ostenberg, D.D.S., M.S. , 1999

http://www.qaproject.org/pubs/PDFs/accredmon.pdf

Assessing Quality, Outcome, and Performance Management

Dr Javier Martinez. WHO, Dept. of Organization of Health Services Delivery, 2001

Report from a Workshop on Global Health Workforce Strategy. Discusses quality as it relates to the performance and management of the health workforce. This background is especially helpful in considering how to link quality measurement with staff incentives.

http://www.who.int/hrh/documents/en/Assessing_quality.pdf

Quality Improvement in the Developing World

Smits H, et. al. International Journal for Quality in Health Care, Volume 14, No 6, 2002

An editorial discussing challenges for implementing QA in the developing world.

Quality Improvement in the Developing World

International Journal for Quality in Health Care, Volume 14, Supplement 1 : December 2002: Quality Assurance in Low and Middle Income Countries

This is a series of case studies and methods papers for QA in developing country health services

Quality Assurance in Low and Middle Income Countries

Quality of Care: A Process for Making Strategic Choices in Health Systems

Bengoa R, et. al. WHO, 2006.

This document provides decision makers at the country level with a systematic process for designing and implementing effective interventions to promote quality in health systems. An annex serves as a self-administered tool to assess readiness to proceed with quality improvement initiatives.

A Process for Making Strategic Choices in Health Systems

A Modern Paradigm for Improving Healthcare Quality.

Massoud R, et. al., 2001 (90 pgs) Quality Assurance Monograph. Quality Assurance Project

This monograph gives an overview of quality improvement methodology, as well as a discussion on how to implement improvement for a paradigm of QA which focuses on a single topic at a time (e.g. a QA program which aims to reduce post-partum hemorrhage mortality rather than improve the coordination and performance of a health service more generally). It also details a number of approaches or “tools” for improvement.

http://www.qaproject.org/pubs/PDFs/improhq601bk.pdf

Quality Assurance of Health Care in Developing Countries

Brown L, et. al. 1998 (33pgs) Quality Assurance Methodology Refinement Series. Quality Assurance Project

An introductory overview of QA for developing countries. A bit dated but a very clear and useful overview. Part I describes how quality assessment and improvement have been carried out in less developed countries. Part II discusses the feasibility and rationale for applying QA in the developing world. Part III proposes some definitions and dimensions of quality. Part IV reviews the definition and basic tenets of QA. Part V presents a simple framework for the QA process, and Part VI discusses the challenges of building a QA program within a health care organization.

http://www.qaproject.org/pubs/PDFs/DEVCONT.pdf

International Journal for Quality in Health Care, Volume 14, Supplement 1 : December 2002: Quality Assurance in Low and Middle Income Countries

(This is a series of case studies and methods papers for QA in developing country health services)

Quality Assurance in Low and Middle Income Countries

External Assessment of Health Care

Shaw C. British Medical Journal 2001 Apr 7;322(7290):851-4

A discussion of what is known about the effectiveness of accreditation approaches by one of the leaders in the field of QA. (Many of these observations apply also to internal assessment).

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1120015&blobtype=pdf

Conference on Quality in Health Care in Low and Middle Income Countries

WHO, Manila, Oct 2007

Presentations and Videos from a Western Pacific regional conference on quality

http://www.qaconferencemanila.ph/

Evaluating Health Care Collaboratives: the Experience of the Quality Assurance Project

Catsambas T, et. al. Collaborative Evaluation Series. USAID Health Care Improvement Project. Bethesda, MD. 2008. KEY REFERENCE

In recent years, the Quality Assurance Project of USAID has adopted the “health care collaborative” approach to spreading QA programs to multiple sites. Briefly, a collaborative is a collection of teams from multiple sites who are brought together for week-long face-to-face workshops several times over a 12-24 month period. Between workshops, the teams stay in contact with one another by conference calls and web/e-mail to share learning as each team strives to establish QA programs at their site. This formal review of this strategy concludes that the collaborative approach to spreading QA programs “is robust and feasible in developing country settings. Caveats and lessons learned are discussed.

http://www.comminit.com/en/node/273888

Whole System Measures

Martin LA, et. al. IHI Innovation Series White Paper, 2007. Institute for Healthcare Improvement.

This paper puts forth a set of 13 balanced system-level measures designed to assist health service leaders with evaluating their systems’ overall performance on both quality and value and to track the impact of improvement activities. The measures that are not disease or condition-specific and span both outpatient and inpatient curative (but not public health) services. The measures are “macrolevel”, each of which is designed to capture multiple important components of the health care process. The paper contains detailed discussion of the definition, likely data source(s), recommended audit frequency, methods, background and implications and recommended target for each measure.

Whole System Measures

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement

IHI Innovation Series White Paper, 2003. Institute for Healthcare Improvement.

Describes the IHI’s “Breakthrough Series Collaborative” approach to spreading quality assurance innovations. These collaborative are 6-24 month seminars that bring together a number of teams from hospitals or clinics to seek improvement in a focused topic area. Each team typically sends three of its members to attend several week-long workshops separated by several month-long “action periods” during which learning session plans and lessons are applied.

The Breakthrough Series Paper

Issue Focus: Accreditation of Public Health Departments

Special issue, Journal of Public Health Management and Practice, Vol 13, No 4, July-Aug 2007.

Contains the Exploring Accreditation Steering Committee final report for the CDC/Robert Wood Johnson Foundation- funded Futures Initiative, which was a consensus development process for bringing together input from all major stake holders regarding the creation of a voluntary national accreditation program for state and local health departments; also contains numerous commentaries from stake holders about various aspects of the proposed accreditation system, and case reports of several accreditation pilot projects at the state and local level. Provides a good overview of the complex process by which the public health sector in the U.S. is slowly moving toward a standardized system of accreditation.

Building Blocks for Public Health: Connecting Standards and Accreditation

This archived June, 2007, 90-minute Webcast prepared for the National Association of City and County Health Officials provides an introduction to, and explanation of, several of the current U.S. public health standards and accreditation tools and frameworks, including the National Public Health Performance Standards Program (NPHPSP), the 10 Essential Services, Mobilizing Action through Planning and Partnerships program (MAPP), Understanding State Public Health Services project, and the Operational Definition of a Functional Local Health Department. The Webcast considers how these projects relate to the emerging voluntary national accreditation program for state and local public health departments.

http://webcasts.naccho.org/webcast/quickreg.php

Performance Improvement Processes: Survey of Tools and Approaches

This PowerPoint presentation explains and compares several popular performance assessment and performance improvement tools and approaches in public health. It gives an overview of the APEXPH (Assessment Protocol for Excellence in Public Health, MAPP (Mobilizing for Action through Planning and Partnerships), NPHPSP (National Public Health Performance Standards Program, PATCH-EH (Protocol for Assessing Community Excellence in Environmental Health) and PATCH (Planned Approach to Community Health). This 2005 presentation by Heidi Deutsch of the National Association of County and City Health Officials is designed to help state and local decision makers understand the purposes, differences, benefits, and limitations of various tools. It defines commonly used terms and lists resources for more information. Heidi Deutsch is available at: hdeutsch@naccho.org or 202-507-4214 www.naccho.org/mapp

The Performance Improvement Process

What are the Best Strategies for Ensuring Quality in Hospitals?

John Ovretveit, WHO Health Evidence Network, 2003

This Health Evidence Network literature synthesis report notes the lack of well-conducted research quality studies on QA and concludes that: “No single quality strategy can be recommended above any other on the basis of evidence of effectiveness, ease of implementation, or costs.”

http://www.euro.who.int/document/Hen/hospquality.pdf

Using Research to Inform Quality Programmes

Ovretveit J, Gustafson D. British Medical Journal 2003; Vol 326 No 5 pgs 759-61.

Discusses the evidence for the effectiveness of various approaches to quality improvement, and the methodological issues related to assessing the impact of QA programs. Concludes that there is little evidence to guide managers in selecting the best QA approach. Suggestions for measuring impact of programs will be useful for designing a QA program evaluation strategy.

http://www.bmj.com/cgi/reprint/326/7392/759

Evidence-Based Quality Improvement: the State of the Science

Shojania K, Grimshaw J. Health Affairs Vol 24, No 1, pgs138-50, 2005.

Another look at the evidence for the impact of quality improvement. Has a useful discussion of the essential elements of change within QA programs (e.g. provider education, audit and feedback, staff incentives) and the evidence showing the impact of these elements.

http://content.healthaffairs.org/cgi/content/abstract/24/1/138

Financial Incentives, Healthcare Providers and Quality Improvements: a Review of the Evidence.

Christianson J, et. al., 2007 (Commissioned by the UK Health Foundation)

Reviews the healthcare literature examining the effect of financial incentives on the behavior of healthcare organizations and individuals with respect to the quality of care they deliver to consumers.

http://www.health.org.uk/document.rm?id=485

Healthy People 2010

Official policy document of U.S. public health goals and objectives. Fifteen of these objectives are specifically related to cancer. Can also search website for others (e.g. tobacco, alcohol and obesity-related objectives, that are also related to cancer.

http://www.healthypeople.gov/document/HTML/tracking/OD03.htm

Catalogue of Health Indicators: A selection of Health Indicators Recommended by WHO Programmes

WHO Unit of Strengthening Country Health Information, Geneva, 1996. WHO/HST/SCI/96.8

Contains some recommended cancer control objectives with indicators.

http://www.who.int/cancer/media/en/408.pdf

National Cancer Control Guidelines- Policies and Managerial Guidelines

2nd edition. WHO, 2002. (ISBN: 92 4 154557 7)

Discusses policy options for national cancer screening, surveillance and management based on local resources and capacity. These policies imply indicators for gauging program effectiveness.

http://www.who.int/cancer/nccp/nccp/en

Discussion Paper for Use of Quality Assurance to Support Comprehensive Cancer Control Activities in PIHOA Jurisdictions

Durand, AM Key Reference

A discussion of options for using QA programs to strengthen Pacific Comprehensive Cancer Control Program activities in PIHOA jurisdictions.

Discussion Paper for Use of Quality Assurance to Support Comprehensive Cancer Control Activities in PIHOA Jurisdictions

Journal on Quality Improvement (previously Quality Review Bulletin) (JCAHO)

http://www.jcrinc.com/journal.htm

Journal of Quality in Clinical Practice (previously Australian Clinical Review) (ACHS, AMA)

http://www.blackwell-synergy.com

International Journal of Technology Assessment in Health Care (ISTAHC)

http://www.journals.cup.org/

International Journal of Health Care Quality Assurance

http://www.mcb.co.uk/ijhcqa.htm

International Journal for Quality in Health Care (previously Quality Assurance in Health Care) (ISQua)

http://www3.oup.co.uk/intqhc/

Quality and Safety in Health Care (previously Quality in Health Care) (IHI)

http://www.qualityhealthcare.com/