Table Of ContentWHO Regional Publications, Eastern Mediterranean Series 26
Quality improvement in primary
health care
A practical guide
Assaf F. Al-Assaf, executive editor
M. Sheikh, editor
World Health Organization
Regional Office for the Eastern Mediterranean
Cairo 2004
WHO Library Cataloguing in Publication Data
Quality improvement in primary health care: a practical guide/ by Assaf F. Al-Assaf, Mubashar Sheikh.
[editors]
p. (WHO Regional Publications, Eastern Mediterranean Series ; 26)
ISBN 92-9021-296-9
ISSN 1020-041X
1. Primary health care 2. Quality of health care I. Al-Assaf, Assaf F.
II. Sheikh, Mubashar III. WHO Regional Office for the Eastern Mediterranean
IV. Series
[NLM Classification: W 84.6]
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Cover by DAT, Cairo
Printed by Al Marsa, Cairo
Contents
Foreword ................................................................................................5
Preface ..................................................................................................7
Contributors ...........................................................................................9
1. Introduction and background........................................................11
Historical perspectives on health care quality...................................11
Definitions and the concept of quality ..............................................14
Quality improvement steps................................................................18
Dimensions of primary health care quality........................................19
Quality and cost................................................................................22
Quality can be measured..................................................................23
References and further reading........................................................26
2. Development of standards and the quality improvement
cycle ...........................................................................................28
Quality improvement cycle................................................................28
Standards ..................................................................................36
References and further reading........................................................55
3. Infrastructure of quality improvement..........................................59
Data collection and display...............................................................59
Developing quality improvement awareness programmes................84
Organization for quality improvement...............................................86
Reference and further reading..........................................................97
4. Planning for primary health care quality improvement
programmes and activities............................................................99
Situation analysis..............................................................................99
Priority setting ................................................................................100
Defining objectives and targets.......................................................101
Standard setting..............................................................................102
Organizational structure..................................................................105
Action plans ................................................................................112
Achieving change............................................................................113
References and further reading......................................................120
5. Implementing quality improvement activities in
primary health care.......................................................................125
Training and quality improvement awareness.................................125
Mobilization of resources................................................................146
Building the quality improvement supportive structure....................153
Analysing constraints and opportunities..........................................157
Integration of supervision into quality improvement.........................168
References and further reading.......................................................171
6. Monitoring and assessment.........................................................178
Monitoring and quality control..........................................................179
Capacity-building for basic epidemiological analysis.......................185
Setting of standards and identifying key indicators..........................186
Development of an indicator for a standard.....................................188
Other assessment and monitoring methods....................................192
References and further reading.......................................................205
7. Certification, licensure and accreditation...................................210
Certification and licensure...............................................................211
What is accreditation?.....................................................................213
Historical perspectives and trends on accreditation.........................216
Why accreditation?..........................................................................218
The benefits ................................................................................222
Components and accreditation........................................................223
HEDIS ................................................................................227
The accreditation process................................................................227
Conclusions ................................................................................228
References and further reading.......................................................229
8. Promotion and sustainability.......................................................231
Management commitment...............................................................231
Leadership ................................................................................239
References and further reading.......................................................264
9. Important areas for quality improvement application................265
Infection control...............................................................................265
Risk management............................................................................278
Utilization management...................................................................282
Outcomes management and quality improvement applications.......287
References and further reading.......................................................295
Annexes
1. Quality assurance and improvement in Egypt.................................301
2. Mechanism for setting standards and measuring performance
in primary health care in Cyprus......................................................310
3. Application of a training programme in quality assurance in
Saudi Arabia ................................................................................321
Foreword
Countries worldwide are beginning to introduce the concept of quality
into their health care systems. This is because the provision of care per se,
any care, is no longer the option. Patients and purchasers alike now demand
that this care be provided with quality. The provision of mediocre care is no
longer acceptable, nor is the provision of care without regard to optimum
resource utilization. And certainly, care that is provided in a haphazard way
is also not acceptable.
‘Quality’ simply means the achievement of the desired objectives in
the most efficient and effective manner, with the emphasis on satisfying the
customer or the consumer. It is not necessarily the most expensive way to do
things. On the contrary, it is a call for efficiency and cost saving. It is not
necessarily the provision of luxury items or services. It is a product or a
service that is acceptable, accessible, efficient, effective and safe, and that is
continuously evaluated and upgraded.
Quality is measurable. A system is usually made up of three
components: input, process and output. Quality of input (structure) can be
measured. This includes the quality of personnel, supplies, equipment and
physical resources. The quality process is also measurable. Diagnostic,
therapeutic and patient care procedures and protocols can all be measured
and quantified. The same is true for system outcomes or results. They too are
measurable. For example, infection rates, morbidity and mortality rates, as
well as patient and employee satisfaction are all outcome measures and are
all measurable variables. Therefore the system components of inputs,
processes and outcomes have certain quality characteristics that are
measurable and are important in quantifying the quality of a system.
It is important that primary health care personnel pursue the same core
functions in relation to public health that other levels now do, especially
those related to assurance of access to cost-effective, appropriate and quality
health care. Primary health care is in the midst of a new era where ensuring
6 Foreword
access to health care is not enough; ensuring access to quality health care is
the goal now.
This manual introduces the concept of, and practical approaches to,
implementing quality assurance and improvement in primary health care.
The authors discuss methods and techniques for the promotion and
sustainability of quality in health care. The manual outlines steps and
techniques for implementing practical applications and procedures and it
should serve as the most widely read and used manual in the field of quality
in primary health care. It is unique to the field of primary health care for its
rich and valuable material and its specificity to both the health sector and the
Eastern Mediterranean Region. I commend the authors and the editors for a
job very well done.
Hussein A. Gezairy, MD, FRCS
Regional Director for the Eastern Mediterranean
Preface
This book is devoted to the issue of quality and its application in
primary health care. It is a collaborative effort between several international
health care professionals, bringing the concept and practice of quality closer
to the daily activities of health professionals. It is intended to be a practical
reference for practitioners in the field and, as such, it is a comprehensive
manual on the different applications of quality assurance and improvement
in health care, in particular in primary health care.
Quality has a number of definitions, although in primary health care,
the most applicable and certainly most important definition is “meeting the
requirements of the customer, both internally and externally, for defect-free
products and services”. Patients, of course, are one important group of
external customers, and providers need to learn about, investigate,
understand and implement methods to satisfy them, and to maintain these
actions. Basically, quality is a process of effective communication between
the supplier or the provider of care or health service and the consumer or the
receiver of that care or service. It is a continuous process of dialogue and
understanding between the two. There are other customers in the system
also: the internal customers, the employees and other external customers
such as patients’ families, visitors, payers, etc. Each has special needs and
expectations and it is the duty of health professionals to meet them if a
quality service is to be the goal in health care, whether private or public.
Quality does not have to be the most expensive or the most prominent
approach or product. It can be as simple as doing one’s job better,
continuously. It can also be as simple as providing appropriate and
necessary care to the right health care consumer in the most efficient manner,
utilizing the current available resources.
This manual was developed in order to introduce the health care
practitioner in the field to the concept, the teachings, the principles and the
8 Preface
applications of quality. It is a manual of practical tips and techniques geared
towards the field practitioner and health care provider in primary health care.
The manual comprises 9 chapters. The first eight chapters discuss the
principles, concepts and techniques of quality improvement and its many
activities; the cycle of quality improvement and the development and
assessment of standards in quality; the quantitative techniques utilized in
quality improvement projects and the structural element of quality, in terms
of both human and physical resources; planning for quality and techniques of
setting objectives and forecasting for activities; the training functions
necessary for the sustainability of quality improvement in health care
organizations; monitoring and assessment, with examples from the USA of
selective monitoring and surveying tools being utilized in primary health
care; accreditation, certification, licensure including the processes of setting
and monitoring standards, and surveying as a method to measure compliance
to standards; and promotion and sustainability. Chapter nine describes
important related areas that are not necessarily a part of the core activities of
quality improvement but that are extremely important for an organization to
implement to be more effective and more efficient in delivering its services.
The annexes describe several quality initiatives that are current or have
recently taken place in the Eastern Mediterranean Region.
Quality improvement efforts are being strongly pursued and supported
by the countries of the Eastern Mediterranean Region. Application of the
techniques and methods presented in this manual can help practitioners to
improve the services and care they provide to their patients, and can improve
regional primary health care. Both the individual countries and the Regional
Office have actively participated in and sponsored efforts towards total
quality improvement and we hope this manual will contribute to sustaining
that momentum.
Assaf F. Al-Assaf, executive editor
Mubashar Sheikh, editor
