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Current QI Trends 

Case Study by 

Jamie Kim, International Health Major, Georgetown University '17

Jamie Kim was born and raised in Los Angeles. She lived in Washington D.C. for 4 years during her college years at Georgetown University. She graduated in 2017 with a B.S. in International Health. As a student, she interned as a research assistant at both national and international health organizations including the University Research Co. in D.C., the WHO Western Pacific in Manila, and Georgetown University Center for Child and Human Development. Jamie’s passion lies in working to close the gap between the demand for and supply of health services for people with disabilities. Jamie is currently continuing her studies at Loyola Marymount University in L.A.

This case study describes current trends in health care improvement and presents some of the questions that relate to these issues. 

Please read the case study below and consider the following questions:

Evolving focus of improvement.
Dr. Massoud started the webinar by sharing his views on the changing focus of quality improvement. Traditionally, health care improvement involved changing just 1 process by using the PDSA (Plan, Do, Study, Act) cycle. For example, improving the care of hypertensive patients in an outpatient clinic involved focusing on reducing waiting times. However, as the field has evolved, improvement experts have recognized the synergistic effect of numerous factors to fully improve patient care. Continuing with his hypertension example, Dr. Massoud stressed that improvement in patient care must involve improving not only waiting times, but also the clinic’s supply chain, health promotion and education, prevention of complications, referral protocols, etc. Improvement is no longer understood to be a simple, linear process, but rather an examination and improvement of the whole system, requiring multiple processes. 

Dr. Barker reinforced Dr. Massoud’s comments with his own example of improving maternal and newborn care, specifically newborn asphyxia. Traditionally, improving the care of babies with asphyxia would include ensuring the staff knows how to resuscitate babies and that the delivery room has everything they need to manage a baby who may have asphyxia. For example, the improvement team may introduce delivery room kits for asphyxia care, conduct staff training on how to recognize asphyxia in a baby, and share knowledge on how to deliver appropriate care. These interventions will work synergistically to successfully resuscitate an asphyxiated baby. However, delivering effect, high-impact improvements requires a broader, whole systems approach. In this case, addressing asphyxia will require that the improvement team branch back from the micro level of just managing asphyxia at birth. Instead, the clinic will have to work its way back up the chain of patient care—how mothers are being managed during labor, how adequately mothers are receiving antenatal care, how the partograph is being used to observe the condition of mother and baby upon admission for delivery, etc. All these elements must be studied together and appropriately improved since patient outcomes are highly dependent on the entire health system environment. The field of quality improvement has evolved to ensure the whole system, not just individual processes, is adequately equipped to deliver overall quality care for good patient outcomes.

The field has evolved in such a way that we know health care improvement is an effective way in yielding results at-scale. Now, one of the key questions is how to institutionalize improvement as a means of doing everyday work. Dr. Massoud believes institutionalization requires multiple levels of action. At the provider level, we have the frontline teams who are actively employing the improvement methods. However, equally important will be the engagement at the higher levels. Called governance, the participation of higher levels is crucial in ensuring the prioritization of improvement, the efficient tackling of major issues, and the generation of significant results.   

Governance can be expressed in various ways, such as by instituting policies to enhance and support improvement activities. For example, some Ministries of Health may create units within the Ministry that specifically support improvement, set priorities, and provide the resources that enable improvement teams to carry out their work. Dr. Massoud cites ASSIST’s success in working with Uganda to create a “quality policy” and essentially integrate quality improvement into its national agenda. Dr. Massoud points to this example, as well as other similar experiences, as a sign of good progress in the arena of institutionalization through governance. 

Addressing Resistance to Change.
Health care improvement is based on making changes to a system to yield high-impact results. Change, though, can be scary because it requires people to move beyond the area they feel most comfortable in. Fortunately, Dr. Barker asserts, many of those who work in health care do so because of an intrinsic motivation to do good. Curiosity and the interest in learning are also common traits amongst healthcare workers. Nurses and physicians, whose everyday tasks are based on science, are naturally interested in data and evidence, both of which serve as foundational elements of change and improvement. In the face of fear and discomfort, these powerful instincts and motivators must be harnessed to mobilize people from all levels to engage in improvement. 

Dr. Barker also states that the beauty of the improvement method is that it allows us to explore and test changes in a very systematic, structured manner. Initially, the method only requires that small changes be tested, on a small scale. So, in the beginning stages, the risk of making blunders while testing changes is relatively small, which can be reassuring to those who are wary. The flow of improvement, starting with small processes and then moving to whole systems, allows the method to gain the confidence of people, especially once great results start to follow. 

Cost of improvement.
During the webinar, participants were keen to hear from Drs. Massoud and Barker about the cost of improvement. The participants’ comments and questions suggest that the cost of improvement is perceived to be high, suggesting that cost is a significant reason for frontline resistance to change. 

Dr. Barker agrees that funding improvement can be challenging, especially since the goal is long-term institutionalization. As previously discussed, a key component of institutionalizing improvement is good governance. In addition, because improvement does not end with just one intervention or program, it requires a more long-term funding model, namely by the government itself. So besides implementing policies and creating specialized improvement units, governance and political commitment must also demonstrate financial commitment. However, the current situation is such that most of the investment is coming from outside sources such as the USAID and foundations or technical partners supporting country governments. To reverse this trend, Dr. Barker asserts that the case for the value of improvement methods and approaches must be fostered. This can be achieved by demonstrating the immense impact improvement can have on health outcomes, such as in terms of number of lives saved. Dr. Massoud points out that demonstrating cost-effectiveness of improvement is also a crucial component to gaining the confidence at higher level, to secure more sustainable funding. As such, while improvement specialists currently place rigorous analyses and evaluations of process and outcomes results high on the agenda, more focus is needed on understanding the costs of undertaking improvement programming. 

Dr. Massoud believes that rigorous analyses and evaluations of improvement activities have not always been assigned their proper worth. Consequently, the field of improvement has been challenged by limited political and financial commitment. Potential funders are interested in the numbers, how impactful their contributions will be, and whether improvement will be the most effective method in yielding positive health outcomes. So, it is crucial to conduct evaluations, such as cost-effective analyses, to address these concerns, demonstrate the effectiveness of improvement, and ensure sustainable, government funding. 

Rigorous analyses and evaluations.
Today, improvement specialists working in the field are claiming lives saved and significant improvements in service delivery. However, how can we be sure that such changes were a direct impact of the improvement activities alone? This can only be guaranteed by conducting rigorous evaluations. Dr. Massoud emphasizes the need to design improvements in such a way that they stand the test of rigor; this is ultimately about demonstrating the attributability of positive health outcomes to improvement activities. For instance, we must test to see if similar changes are occurring in places where improvement activities were not carried out, and if they did, to what extent? If not, more analyses must be carried out to assign attributability of the results to improvement. Drs. Massoud and Barker contend that the field is rapidly evolving to institute these evaluations as an integral component of improvement activities. 
Reducing the use of jargons and fads.
Improvement is based on a very straightforward and simple theory of change. However, the plethora of jargon and the use of brand names to refer to the same concepts can get in the way of understanding the concept. Dr. Massoud recalls a time he passed out his business card to members of a certain Ministry of Health. It read: “Director of Health Care Improvement Project.” Their reaction, upon reading it, was, “Health care improvement, quality improvement, performance improvement—what’s the difference?” Both he and Dr. Barker assert that we need to simplify the language and get rid of all the nonessential terms, which only serve to complicate the core objective of improvement: to better patient care and to implement cost-effective, quality health care.  

Concluding Remarks
During the webinar, Drs. Massoud and Barker gave a commentary on current trends of quality improvement. Many important questions and issues were raised, such as the focus on governance and the crucial role it plays in sustainability. We have also learned how the priorities of improvement shift to meet the evolving needs of health systems. For example, the institutionalization of rigorous evaluations and cost-effectiveness analyses, as well as the reduction of jargon have been highlighted as some of the rising priorities among improvement specialists. We thank Drs. Massoud and Barker for sharing their knowledge, insights, and excitement about the rapidly evolving field of improvement. 

(Please note all answers must be a minimum of 150 words)
Assume that your technical guidance has been requested. Your task is to provide solutions to important issues facing improvement. Allow the following prompts to guide your input on how to make improvement sustainable and effective in producing good health outcomes.  

1. The scale-up of improvement requires strategic partnerships and collaboration. Identify potential partners and their respective responsibilities in maximizing the reach of improvement.

2. The integration of improvement into a country’s general health policy requires that its government also assume financial responsibility for the improvement efforts. At what point would a fiscal handoff—from external funders such as USAID to the country itself— be appropriate in your context?
3. Identify major cost-related barriers that prevent countries and healthcare facilities from eagerly adopting improvement measures. Propose solutions to solve these issues. 

4. It is crucial that results are front and center, to demonstrate the important impact of improvement measures and garner support. Thinking about your context, how can the field of improvement be more systematic about the way it designs, evaluates, and tracks programs to strengthen the results of these programs? 

5. How can health care workers (i.e. nurses, health facility administrators, physicians) and even patients be galvanized and sufficiently supported to lend their support in instituting improvement?