Many researchers before Avedis Donabedian (2005) claimed the concept of quality in healthcare could not be defined in concrete objective terms because it is practically challenging to apply it in the health services industry. In more recent times, the Institute of Medicine (IOM) stated that quality care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. The IOM (2001) proposed that high quality should be:
- Safe – avoiding injuries to patients from the care that is supposed to help them
- Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
- Patient-centered – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
- Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care
- Efficient – avoiding waste, in particular waste of equipment, supplies, ideas, and energy
- Equitable – providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status
Quality care has also been classified into technical (adherence to standard protocols and guidelines of care) and functional (staff attitudes, facility physical cleanliness, waiting times, staff punctuality and respect/compassion for clients). These different dimensions to quality healthcare are not mutually exclusive in quality improvement efforts because empirical studies show that emphasis of technical quality improvement over client-perceive quality could render the former meaningless (Robyn et al, 2013).
Effective balancing of client-perceived quality with technical quality improvement endeavors will likely bridge communication gaps and knowledge asymmetry between service providers and healthcare clients. This balance can help meet clients’ needs and at the same time mitigate unrealistic expectations. Health care providers can also take advantage of this multi-prong approach to do adequate self introspection of the quality of services they render to clients.
With increasing client knowledge levels in health information due to technological advancement, demand for more accountability from service providers by clients has increased. In view of this, there is the need to recognize the critical role of clients in quality assessment and improvement. Adopting this new approach by health care systems in resource constrained settings such as sub-Saharan Africa, could help reduce litigations against service providers, maximize profit and enhance service utilization. This will ultimately result in improved health outcomes of individuals and communities.
Furthermore, improvement in client-centered healthcare services while maintaining technical quality standards can contribute towards sustaining health financing options such as social and community health insurance. This is because increased client confidence and trust in the healthcare system could stimulate communities’ willingness to participate in health insurance which in turn will improve (re)enrolment rates and promote viability of such health financing initiatives.
To contribute towards realizing a client-centered healthcare system, the WOTRO-COHEiSION project was initiated in 2011 in Ghana. As part of the intervention activities to actively engage clients and communities in quality improvement and participation in health insurance, a Community Engagement intervention was implemented in 8 intervention districts and 32 health facilities in two administrative regions. Existing community associations and groups were actively engaged to monitor and appraise the quality of primary health facilities in the intervention districts. The community group assessment findings were fed back to the health facilities after which they were encouraged to institute measures to address the identified gaps in service quality within a specified period of six months. A second round of monitoring and appraisal was done and deserving facilities who were adjudged by clients as having addressed most of their identified gaps were rewarded with citations and token incentives (see report). An initial evaluation of this client-centered intervention reveals that clients’ perception of quality at the facility level has improved. It is envisaged that this positive outlook will induce increased enrolment and utilization at the NHIS-accredited facilities.
A full impact evaluation will be done later this year (2014) by the project to ascertain the impact of these interventions in improving quality healthcare and client participation in Ghana’s health insurance system. It is expected that lessons learnt, will be shared with key stakeholders and policy makers through dissemination platforms such as media and policy briefs. Countries in the African region, such as Ethiopia, which are at various stages of health insurance and quality care improvement interventions, could also learn from Ghana’s experience.
In conclusion, irrespective of how the client or health provider perceives quality in healthcare, quality improvement interventions necessarily need the different dimensions to attain health goals and desired public health outcomes.
References
- Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. National Academy Press. March, 2001 (Accessed on 21/08/2012 from http://www.nap.edu/books/0309072808/html)
- Robyn PJ, Bärnighausen T, Souares A, Savadogo G, Bicaba B, Sié A, Sauerborn R: Does enrollment status in community-based insurance lead to poorer quality of care? Evidence from Burkina Faso, International Journal for Equity in Health, 2013, 12: 3
- Donabedian A: Evaluating the Quality of Medical Care, The Milbank Quarterly, 2005, 83 (4): 691–729