Knowledge Summary 7: Assure quality care
Achieving high and equitable coverage of interventions for reproductive, maternal, newborn and child health (RMNCH) is essential, but saving lives also depends crucially on the quality of care. Each country context presents a different set of challenges for assuring quality care that is effective, safe and a positive experience for women and children.The greatest possibility of success comes from multifaceted interventions that address quality issues throughout the health system and are supported within a progressive policy environment. Providers must embed quality care assurance at all levels of the health system, and view it as essential to achieving health and survival goals for women, adolescent girls, newborns and children.
One of the simplest definitions of quality of care in health is care that is “clinically effective, safe and a good experience for the patient.” A more comprehensive description refers to quality of care in terms of meeting standards in ways that are: safe, effective, patient-centered, timely, efficient and equitable.
What is common to all definitions is the need to see quality of care as much more than just a matter of technical skills and the supply of services. Good quality care must also respect the perspectives and needs of the patient or client. One definition that clearly shows this for maternal health, states that quality of care is: “the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights.”
What do we know?
We know that the technical competence, motivation and interpersonal skills of health workers determine their individual performance. However, it is clear that this also depends on quality issues at a management level, such as coordination and linking of services, adequate supplies and ongoing supportive supervision (see Knowledge Summaries 5 and 6).We also know that, although access to services has been improving, women still do not always seek appropriate care for themselves or their children. This is partly due to distance and costs, but also because of earlier experience of disrespectful treatment from health workers, or adverse perceptions of the facilities and providers.
Many context specific lessons about improving quality have already been learned.These encompass technical models such as quality assurance, continuous quality improvement and total quality management. These approaches aim to improve healthcare quality continually, while also taking into account the needs of the service and those of women and children. The specific quality improvement actions taken are typically based on the data and evidence gathered by healthcare managers and their teams.Continuous education benefits health care workers’ practice
Continuous education and training are known to improve the motivation and performance levels of health care workers. The most effective approaches are those that involve active participation of these workers, including educational outreach visits, interactive workshops and small group tutorial sessions. Although the use of manual reminders can help, distribution of educational material is ineffective unless combined with continuing education. Providing such support through outreach to workers does, however, involve higher costs and is often harder to sustain.Continuous monitoring, feedback, supervision and support improves quality of care
Mechanisms such as clinical audits and regular feedback are useful,9 particularly in contexts where quality is very poor,10 and training and supportive supervision make audits more effective. In Kenya, healthcare workers who received supervision, support and feedback at each stage of service delivery for mothers and newborns achieved improved skills scores.11 Similarly, a package to improve postnatal counseling also helped to improve the quality of care in Kenya,12 and criterion-based audits, combined with management support resulted in strengthened referral system for mothers and babies in Malawi.
Maternal and perinatal death audits and reviews are now used in many countries. When these are well-conducted, such audits can provide valuable information to improve services and clinical practice. However, realizing the full benefits from applying these quality assessment tools can be undermined by limited resources, poor management or institutional procedures, and in some cases can also create tensions within a team. In Tanzania, for example, there was inadequate discussion during audits conducted at some of the main urban hospitals and the recommendations were not implemented, which demoralized the team.14 Again, these experiences from the field highlight the need for an enabling management and wider health systems environment in order to achieve the full benefits from essential audit and feedback mechanisms.Supportive national policies are essential to quality assurance
Poor quality infrastructure and healthcare practices can be improved through nationally recognized quality standards, certification and accreditation measures. These can be applied to service institutions, medical education and training institutes and other healthcare organizations – both in the public and private sectors. Community-level monitoring of services through patient welfare committees, public hearings and assurance mechanisms were widely used, which led to strengthened infrastructural and human resources. However, increased demand for services created additional pressures that compromised quality.Enhancement of infrastructure and services must be an integral part of quality improvement
In contexts where services are hard to reach, service developments such as the introduction of maternity waiting homes (centers within easy reach of clinics, or hospitals where women can wait close to the time of childbirth) and support for referral transport are key. Although there is little hard evidence of their effectiveness at improving outcomes,17 some studies report benefits – for example, in Cuba, Nicaragua and Ethiopia. Birth companions have also been suggested to improve timely uptake of care, as well as mothers’ experiences of childbirth, although the benefits are likely to vary by context. A pilot study in South Africa, did not find any difference in care received when women had birth companions, whereas various schemes to improve uptake by reducing transport barriers have been more successful. For example, a current scheme in India to improve facility-based care includes a reimbursement towards transport costs for women.Involving communities helps to improve demand for quality care
Community participation on issues such as training of healthcare workers, community education, selection of health committees, supplies and referral systems, have been useful in improving quality. For example, a review found that community participation helped to increase clean delivery practices. Although lack of education and literacy are often barriers to effective community involvement, mass media campaigns on health issues (through radio, television, newspapers, magazines, posters, etc.) can be used to improve public knowledge, and thereby demand for quality health services.
A progressive policy environment is essential to embedding quality assurance at all levels of the health system. Quality improvement interventions for RMNCH care that are multifaceted and tailored to specific contexts are more likely to achieve good results. Efforts towards quality improvement can thus not only strengthen the health system, but crucially also ensure women, adolescent girls, newborns and children receive the effective, safe and respectful care they need and deserve.