Transcript TPHA - Conference 20 - 24 Nov. 2000 Comprehensive Quality

MPH-Course 2003
Quality Management
Step 1
Introduction and Definitions
 Extract form the “Hammurabi codex” 5000
b. c.
 If a master builder builds a house and fails to make it strong
enough, so that it collapses and causes the death of the builderowner, this master builder shall be killed.
 If the collapsing house kills a son of the builder-owner, a son of
the master builder shall be killed
Some definitions on Quality of Care:

1. “Quality of care is the extent to which
actual care is in conformity with preset
criteria for good care.”
(Definition by
Donabedian)
2. Quality of health care is the production of
improved health and satisfaction of
population within the constraints of existing
technology, resources, and consumer
circumstances.
(Definition by Donabedian, Palmer, Povar)
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3. Quality of 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.
(Definition by Lohr)
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4. Quality of care is the performance of specific
activities in a manner that either increases or at
least prevents the deterioration in health status
that would have occurred as a function of a
disease or condition. Employing this definition,
quality of care consists of two components:
.the selection of the right activity or task or
contribution of activities, and
.the performance of those activities in a manner
that produces the best outcome.
(Definition by Brook, Kosecoff)
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5. Appropriate care means that the expected health benefit
(increased life expectancy, relief of pain, reduction in anxiety,
improved functional capacity) exceeds the expected
negative consequences (mortality, morbidity, anxiety of
anticipating the procedure, pain produced by the producer,
misleading of false diagnoses, time lost from work) by a
sufficiently wide margin that the procedure is worth doing.
(Definition by Chassin, Park, Fink)
According to WHO:

“Quality as a characteristic of health care may be understood at two different
levels. At the more general level, one may speak of the quality of the health
care system as a whole. In this approach, the resources, the activities, the
management, and the outcomes of health care are all implicated: quality is the
merit or excellence of the system in all its aspects.

At a more restrict level, quality may be considered to be one of the features
of the health care resources and activities. Do they comply with certain
established standards? Thus, it may be stated that the attributes of a
given set of resources included: their category or type, their quantity, their
unit cost and their quality..

The attributes of a set of activities include: their type, quantity, effectiveness
in regard to the health problems addressed, coverage of the target
population, and quality, . In this perspective, the outcomes or effects of the
system would depend o the attributes of the resources and activities,
including their quality. The quality and other attributes of the resources and
activities would themselves depend on the financing, resource
development, planning, organization, and management of the system. The
more restricted view of quality makes it possible to handle it as a set of
variables that can be easily defined, measured, assessed, and improved. It
is, therefore, quite appropriate for operational purposes.”
Seven attributes of health care define its quality:
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Efficacy: the ability of care, at its best, to improve health
Effectiveness: the degree to which attainable health
improvements are realized
Efficiency: the ability to obtain the greatest health improvement
at the lowest cost
Optimality: the most advantageous balancing of costs and
benefits
Acceptability: conformity to patient preferences regarding
accessibility, the patient practitioner relation, the amenities, the
effects of care, and the cost of care
Legitimacy: conformity to social preferences concerning all of
the above: and
Equity: fairness in the distribution of care and its effects on
health.

Five key elements for good quality
 The working place (hospital, HC, ) is equipped according to
assigned tasks
 .Adequately trained and motivated staff is available in sufficient
number
 .Standards and norms exist and are utilized
 .The client is satisfied by the service offered to him
 .“We can do even better” is shared by everybody (room for
improvement)

Quality Control
 Quality control focused mainly on the
quality of products without taking into
account the “human factor”

Quality assurance/assessment
 People are making mistakes, therefore
they must be controlled. If you control
them very carefully, they make less
mistakes. This approach focuses on
inspection, supervision, checklists,
guidelines etc.

Comprehensive Quality Management /
Continuous Quality Improvement
 The majority of the people is willing to
perform will. Problems are mainly caused by
the procedures and processes in place.
These are often too complicated, faulty and
incorrect. Together with the people involved, it
should be possible to improve such
procedures and processes. CQI puts client’s
satisfaction into the focus.
Common Demotivators
 No opportunity to
influence
 Strict hierarchies
 Low salaries
 Boring tasks
 Staff fluctuation
 Lack of corporate
identity
 No recognition
 Insufficient resources
 Physical / mental
stress
 No career prospects
 No room for
creativity
Step 2
Quality of Care Policy in
Tanzania

CQM includes all levels of the health system
 The MOH formulates policies, provides standards and guidelines for
health care delivery and quality monitoring as well as training manuals.

The professional organisations should be involved in developing
performance standards and guidelines (code of conduct).

The RHMT co-ordinates the CQM activities in the Region
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The Local Government has got the overall responsibility for the district
health system.

The DHMT is responsible for the close follow-up (supervision, MTUHA, but
can also initiate quality circles and peer groups).

The health workers themselves are responsible for their performance with
regard to their client’s needs.

Finally the clients and their representatives in the community have to be
involved in the process of improvements, too.
 Some key - statements in the foreword:

The mission of the MoH is to provide the highest affordable quality of
Health services

This training introduces health workers to the concept of quality
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Quality assurance focuses on assisting health workers to achieve full
potential through improvement of the systems and processes

Its primary goal is to support health workers rather than blame
individuals

Quality of care can ensure greater satisfaction for the clients

Definitions
 Quality is a measure of how good something is. Something
has quality if the object or the service meets or exceeds the
expectations of the user. There are various definitions of
quality.
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Respect of standards
“Doing the right think in the right way at the right time”
Doing best with the resources available
 Components of quality
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1. Policy
2. Technical competence
3. Efficiency
4. Interpersonal relationship
5. Effectiveness
6. Accessibility
7. Continuity
8. Safety
9. Acceptability
10. Equity
 Policy:

Thus it is important for the government to have sound policies
to protect the poor, unprivileged and the at risk groups as one
aspect of quality of care
 Equity

There are two dimensions to ensuring equity in health care.
These are the issue of density and geographical distribution of
health services and equitable funding in the national health
system.
According to the guidelines Quality contains also:
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How to plan?
Monitoring and evaluation
Supportive / facilitative Supervision
Managing Time, Space, Equipment and Supplies
Communication in Health care
Organization a Health Education Session
Population Estimates in Health Services
Utilization of Data in Health Facilities
 The guidelines don’t answer the following
questions:
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Quality in Health as a Public issue
Scoring and Ranging
Quality circles / Peer group review
Continuous Quality Management as a new concept
Accreditation/ Certification / Licensing
Summary:
 Quality assurance in Tanzania has
become an issue for the MoH and
the different departments, but a clear
concept is yet lacking.
Step 3
Concepts and Tools
Frameworks for
Quality Management
 ISO
9000 ff
 EFQM
 Focus on processes
 The European Foundation for
Quality Management,
Non prescriptive, comprehensive

What is ISO?

The International Organization for Standardization (ISO) is a
worldwide federation of national standards bodies from some 140
countries, one from each country.

ISO is a non-governmental organization established in 1947. The
mission of ISO is to promote the development of standardization
and related activities in the world with a view to facilitating the
international exchange of goods and services, and to developing
cooperation in the spheres of intellectual, scientific, technological
and economic activity.
 ISO's work results in international agreements which are published as
International Standards.

What are standards?

Standards are documented agreements containing technical
specifications or other precise criteria to be used consistently
as rules, guidelines, or definitions of characteristics, to
ensure that materials, products, processes and services are
fit for their purpose.

For example, the format of the credit cards, phone cards,
and "smart" cards that have become commonplace is
derived from an ISO International Standard. Adhering to the
standard, which defines such features as an optimal
thickness (0,76 mm), means that the cards can be used
worldwide.
 International Standards thus contribute to making life simpler,
and to increasing the reliability and effectiveness of the goods
and services we use.
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How are ISO standards developed?
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ISO standards are developed according to the following principles:

Consensus
The views of all interests are taken into account: manufacturers,
vendors and users, consumer groups, testing laboratories,
governments, engineering professions and research organizations.
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Industry-wide
Global solutions to satisfy industries and customers worldwide.
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Voluntary
International standardization is market-driven and therefore based
on voluntary involvement of all interests in the market-place.
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There are three main phases in the ISO standards development
process.
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First phase: involves definition of the technical scope of the future
standard. This phase is usually carried out in working groups which
comprise technical experts from countries interested in the subject
matter.
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Second phase: Countries negotiate the detailed specifications
within the standard. This is the consensus-building phase.
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Third phase: comprises the formal approval of the resulting draft
International Standard
 It is now also possible to publish interim documents at different stages in the
standardization process.
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Most standards require periodic revision. Several factors combine
to render a standard out of date: technological evolution, new
methods and materials, new quality and safety requirements. To
take account of these factors, ISO has established the general rule
that all ISO standards should be reviewed at intervals of not more
than five years. On occasion, it is necessary to revise a standard
earlier.
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To date, ISO's work has resulted in some 12 000 International
Standards, representing more than 300 000 pages in English and
French (terminology is often provided in other languages as well).
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A list of all ISO standards appears in the ISO Catalogue.
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EFQM
 The EFQM Model is a non-prescriptive framework recognizing
that there are many ways to achieve sustainable excellence. It
helps organizations to understand the gaps, and allows them to
stimulate solutions.
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Why EFQM?
 Quality management tool
 It is sector-independent
 Helps to understand the gaps
 Gives components to estimate whoeness
 Makes organization ask ”How?”
Key statement of the EFQM Model
Customer Satisfaction, People (employee)
Satisfaction and Impact on Society are achieved
through Leadership driving Policy and Strategy,
People Management, Resources and Processes,
leading ultimately to excellence in
Business Results.
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What is EFQM Excellence Model?
 History of EFQM
The European Foundation for Quality Management (EFQM) was
founded by the presidents of 14 major European companies in 1988.
 EFQM’s mission is:
To stimulate and assist organizations throughout Europe to participate
in improvement activities leading ultimately to excellence in customer
and employee satisfaction, influence society and business results; and
to support the managers of European organizations in accelerating the
process of making Total Quality Management a decisive factor for
achieving global competitive advantage.
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Overview of EFQM Excellence Model
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The EFQM Model is a non-prescriptive framework that recognizes there are
many approaches to achieving sustainable excellence. The model’s framework
is based on nine criteria. Five of these are ‘Enablers’ and four are ‘Results’. The
‘Enabler’ criteria cover what an organization does. The ‘Results’ criteria cover
what an organization achieves. ‘Results’ are caused by ‘Enablers’. The nine
criteria are:
 Leadership
 Policy and Strategy
 People
 Partnership and Resource
 Processes
 Customer Results
 People Results
 Society Results
 Key Performance Results
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EFQM gives great ground for self-estimation.
The EFQM Model for Business Excellence
People
Satisfaction
90 points (9%)
People
Management
90 points (9%)
Leadership
100 points
(10%)
Policy &
Strategy
80 points (8%)
Resources
90 points
(9%)
Enablers 500 points (50%)
Processes
140 points
(14%)
Customer
Satisfaction
200 points (20%)
Business
Results
150 points
(15%)
Impact on
Society
60 Pkte (6%)
Results 500 points (50%)
The two categories of criteria of
the EFQM
• Enabler criteria are concerned with how
the organisation undertakes key activities.
• Results criteria are concerned with what
results are being achieved.
The EFQM Model for
Business Excellence
1. Leadership
How the behaviour and actions of the executive team and all other
leaders inspire, support and promote a culture of Total Quality
Management.
Evidence is needed of how leaders:
1a.
visibly demonstrate their commitment to a culture of
Total Quality Management
1b.
Support improvement and involvement by providing
appropriate resources and assistance.
1c.
are involved with customers, suppliers and other external
organisations.
1d.
recognise and appreciate people´s efforts and achievements.
The EFQM Model for
Business Excellence
2. Policy and Strategy
How the organisation formulates, deploys, reviews and turns
policy and strategy into plans and actions.
Evidence is needed of how policy and strategy are:
2a.
2b.
2c.
2d.
based on information which is relevant and comprehensive.
developed.
communicated and implemented.
regularly updated and improved.
The EFQM Model for
Business Excellence
4. Resources
How the organisation manages resources effectively and efficiently.
Evidence is needed of how:
4a.
financial resources are managed.
4b.
information resources are managed.
4c.
supplier relationships and materials are managed.
4d.
buildings, equipment and other assets are managed.
4e.
technology and intellectual property are managed.
The EFQM Model for
Business Excellence
6. Customer Satisfaction
What the organisation is achieving in relation to the satisfaction of its
external customers.
Evidence is needed of:
6a.
the customers perception of the organisation´s products,
services and customer relationships
6b.
additional measurements relating to the satisfaction of the
organisation´s customers.
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
Deming - Cycle
of continous improvement
check
(Q-assurance)
(implementation
management)
do
act
plan
Q-policy / planning
(standardise
improve)
Tools for QM
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The Deming Cycle
Ishikawa (fish
bone) diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
 Causes and effect diagram
Resources
Inappropriate
Rules
Insufficiently elaborated
Problem
Inprecise
Procedures
Lack of knowledge
Personnel
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
INPUT
20%
0%
T
L
U
S
E
R
-50%
80%
100%
Pareto Kurve
50%
100%
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
Review by colleagues with
the same or similar
qualification and
experience
Tools for QM
Benchmarking:
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
... the continuous process of
measuring products,
services and practices
against the leading health
care providers.
Lead question:
Not only who is best, but
how can I become best
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
 Guidelines:
Instructions or principles, which precisely
describe actual or future ways of acting
 Standards
Standards are fixed indicators which are
derived from actual practice and are
generally used to compare medical care
in one setting with that in another
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement
teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
 Quality discussions
 Project groups
 Quality circles
Quality Circles
 Voluntary peers (preferably without hierarchy)
 Self selected problems/topics
 Moderated group discussion
- up to 15 participants
- inclusion of experts on request
- increased job satisfaction
- continuous learning
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
Self-Assessment is a
comprehensive,
systematic and regular
review of an
organisation’s activities
and results referenced
against a model of
excellence
Example for self-assessment
Criterion
Every day there are ward rounds in each ward
with documentation on the inpatient card
All deliveries are monitored by a partograph
In all wards a morning meeting to share
information on crucial events takes place
All maternal and infant deaths are audited and a
written document exists
All wards of the hospital have a functioning
water supply and functioning toilets
Yes
No
Self-assessment in regard to HIV/AIDS at
Hospital Level
Criterion
Are we sure that all blood transfusions are tested for HIV- and
Syphilis?
Are the results of our laboratory checked in a quality
assurance process?
Is there always a laboratory technician on call providing these
test also outside working hours?
Do we have a functioning VCT-service at our hospital?
Do we have a correct waste management of infectious
material (needles, blood bags, syringes?)
Do we offer to all dismissed PLWA provide home base care?
Is equipment sterilized according to guidelines?
Yes
No
Self-assessment in regard to HIV/AIDS at
HF- Level
Criterion
Is the STD-service integrated with FP and MCH service?
Does the STD-Clinic take place every day?
Is the STD register book filled correctly?
Are the STI drugs always availably and stored safely?
Is there a minimum equipment to provide SDI services?
Are condoms available in the catchment area of the health
facility?
Was the health education on STDs and HIV/AIDS done
by the health facility staff?
Are all instruments correctly sterilized?
Yes
No
Personal self-assessment in regard to HIV/AIDS
at HF-Level
Criterion
Do I keep always privacy?
Do I examine patient correctly (patient undressed,
genitalia exposed – adequately, foreskin retracted)?
Do I perform always a vaginal examination if needed?
Do I always emphasize partner notification?
Do I always demonstrate the correct use of condoms?
Do I have the most updated version of the STI treatment
guidelines at hand?
I never run out of condoms during the last 6 months
I always follow up my patients if the don’t respect the
revisit appointment?
Yes
No
Introducing QM
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Announcement of quality policy by leadership
Introduce basic principles of QM to DHMT
Self Assessment
Prioritisation of areas for improvement
Training of moderators
Formation of quality circles
Plan of action and indicators
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
Special projects initiated
to improve particular
quality aspects which
have been identified as a
problem
Tools for QM
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The Deming Cycle
Ishikawa (fish bone)
diagram
Pareto analysis
Peer review
Benchmarking
Quality
improvement teams
Guidelines,
standards
Improvement
projects
Self assessment
External
assessment, audit
Accreditation/certification/awards
In-depth assessment and
evaluation of efficiency
and effectiveness of the
structure and processes of
an organisation or section.
Audits are carried out by
independent specially
qualified experts.
Step 4
Framework for QM in the German
Health System
BASIC PRINCIPLES OF THE
GERMAN HEALTH CARE SYSTEM
• First: Principle of solidarity
- everyone should have access to the
same quality of care on equal terms
independent of financial means
* the wealthier pay for the poor
* the young pay for the old
* the healthy pay for the sick
* small families (singles) pay for
large families
BASIC PRINCIPLES OF THE
GERMAN HEALTH CARE SYSTEM
• Second: Principle of
Supplementarity
- government as regulator only when the
system fails to meet social goals
* government spends relatively little
directly on health care
* government is only marginally
involved in direct service provision
* the health care sector is left to
govern itself, within set federal
rules
BASIC PRINCIPLES OF THE
GERMAN HEALTH CARE SYSTEM
"Governance by Competition"
• Third:
Patients have freedom of
choice of doctors and
hospitals
- uniform compensation system for
providers
Step 5
Quality Management in
Tanga Region
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Why introduce CQM in Tanzania

The applied methods and tools for quality monitoring in
district services include traditional ones like
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Integrated regular supervision of all health facilities
(HF) by the DHMT
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Reporting by using the MTUHA system
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Training of health workers to improve technical and
communication skills
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Active community participation

Supervision has proved to be of limited
effectiveness, with two major problems:
 As the responsibility for quality is not shared by the staff as a
whole, but becomes the specialty of the supervisors, the
supervision easily becomes perverted to a mere control with the
threat of sanctions, the staff rather trying to hide problems than
discussing them frankly. Even if staff manages to “survive”
supervision, daily practice hardly improves.
 Superiors who are supposed to supervise, tend not to like this
job and prefer to stay in their office, consulting room or theatre.
 There is a huge network of HF but low
level of quality
 Q-control / Q-assurance (supervision,
HMIS) with little impact so far
 HSR can only succeed if quality of care is
improving
 People request better quality (cost
sharing)
New quality tools
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Commitment of leadership
Health workers themselves take responsibility for
monitoring (e.g. in quality circles)
Client / community satisfaction with the health services is
considered as important part of quality
Strict monitoring using a standardised set of indicators
with scoring and ranking of the health facilities according
to their performance
Information of the public and local authorities (and creating
public concern)
Awarding of well performing services

How the 8 areas of CQM were assessed in Tanga
Region?
 During routine supervision once per quarter a checklist was
filled by checking topics related to these 8 areas
 An additional annual questionnaire focused mainly on output
indicators
 A third questionnaire was worked out to assess user satisfaction
 The findings of these three questionnaires were computer
proceeded by the CHMT themselves and analyzed by a
computer based ranking and scoring approach
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Further steps of CQM in Tanga?
 Awarding of good performing HF during the Public Health Day
 Regular supervisions are crucial to assess the performance of
all Health Services
 Individual instructions and support by the DHMTs for low
performing HF’s
 Annually information of the public about quality in the health
sector
 Constraints to overcome
 Scoring and ranking is only fair, if all CHMTs conduct regular
supervision and fill in the supervision checklist thoroughly
 There should be a fair competition between private and public
providers. Criteria are lacking, how to compare the
performances of both systems
 How to take into account factors like “remoteness” and “lack of
staff” on which the staff itself has no impact?
Case study: QM in a Tanzanian Health Region
 Health indicators in Tanga Region in %
1. Utilization rate of curative care (visits/ inhabt./year)
2. DPT 3 coverage of children < 1 y
3. ANC First Attendances
4. Proportion of deliveries with medical assistance
5. Proportion of caesarian sections per expected births
6. Maternal mortality among reported deliveries
7. Couple Year Protection (CYP)
8. Detection rate of new TB cases
9. Bed occupancy rate in Hospitals
10. Case Fatality Rate of Malaria in all HUs
11. HIV-Prevalence among blood-donors in
12. Severe Malnutrition Rate
13. Safe water in surveyed households
14. HH with acceptable toilets
54.2
86.1
86.1
43.7
1.5
0.3
16.4
0.2
73.6
3.9
8.5
5.1
44.8
77
Case study: QM in a Tanzanian Health Region
Why introduce CQM in
Tanzania?
Case study: QM in a Tanzanian Health Region
The applied methods and tools for quality monitoring in
district services include traditional ones like
 Integrated regular supervision of all health facilities
(HF) by the DHMT
 Reporting by using the MTUHA system
 Training of health workers to improve technical and
communication skills
 Active community participation
Case study: QM in a Tanzanian Health Region
New quality tools






Commitment of leadership
Health workers themselves take responsibility for monitoring
(e.g. in quality circles)
Client / community satisfaction with the health services is
considered as important part of quality
Strict monitoring using a standardised set of indicators with
scoring and ranking of the health facilities according to their
performance
Information of the public and local authorities (and creating
public concern)
Awarding of well performing services
Case study: QM in a Tanzanian Health Region
 There is a huge network of HF but low level
of quality
 Q-control / Q-assurance (supervision,
HMIS) with little impact so far
 HSR can only succeed if quality of care is
improving
 People request better quality (cost sharing)
Case study: QM in a Tanzanian Health Region

Adaptation of the EFQM
model to local needs
Case study: QM in a Tanzanian Health Region
People
Management
90 points (9%)
Leadership
100 points
(10%)
Policy &
Strategy
80 points (8%)
Resources
90 points
(9%)
Enablers 500 points (50%)
People
Satisfaction
90 points (9%)
Processes
140 points
(14%)
Customer
Satisfaction
200 points (20%)
Business
Results
150 points
(15%)
Impact on
Society
60 Pkte (6%)
Results 500 points (50%)
Case study: QM in a Tanzanian Health Region
 EFQM

Leadership







People Management
Resource Management
Processes
People satisfaction
Consumer Satisfaction
Impact on Society
Business Result
Adaptation
Leadership
Personnel Management
Resource Management
Health Care Performance
Staff Satisfaction
Client Satisfaction
Health Service Output
Health Service Outcome
Case study: QM in a Tanzanian Health Region
 HF provide good CQM, if




1. Leadership
2. Personnel Management
3. Resource Management
4. Health Care Performance
 5. Staff Satisfaction
 6. Clients Satisfaction
 7. Health Service Output
 8. Health Service Outcome
is strong
is powerful
is appropriate
is in line with national and
international standards
Staff is motivated and satisfied
at the working place
Clients attend and appreciate
the HF
HF achieve set goals
is strengthened by the HF
Case study: QM in a Tanzanian Health Region
 Step 6:
 Organization of a baseline study to
get data on service quality
Case study: QM in a Tanzanian Health Region
 How the 8 areas of CQM were assessed in Tanga Region?
 A baseline study was perceived by the Regional Health Management
Team as the starting point of the CQM process
 Elaboration of appropriate questionnaires by the RHMT
 All public health facilities in the Region were visited by DHMT members,
who applied the questionnaires
 Analysis of the results and scoring of the HF according to their
performance
Case study: QM in a Tanzanian Health Region

Main
Questionnaire
3. How the questionnaires look like?
User
satisfaction
Client
satisfaction
Case study: QM in a Tanzanian Health Region
OPD

Handeni
Tanga Region

No HF
32
154













Privacy provided
Patient greeted
Pat. given enough time to explain
Appropriate counselling
History taken
Proper examination
Appropriate lab investigation
Diagnosis consistent
Treatment accordingly
Drug dosage appropriate
Pat instructed correctly
Card filled correctly
Pat understanding checked
59%
43%
67%
38%
60%
51%
7%
64%
68%
64%
41%
56%
41%
54%
44%
32%
32%
52%
42%
10%
53%
58%
58%
45%
50%
26%
Case study: QM in a Tanzanian Health Region

Family Planning












Handeni
Qualified FP nurse/midwife available 81%
FP service offered daily
94%
HF offers pills
78%
HF offers injectables
84%
HF offers IUD
31%
HF offers condoms
69%
HF ensures privacy
81%
FP cards correctly filled in
66%
Pills out of stock
31%
Injectables out of stock
25%
IEC available
72%
Assess drop outs
47%

Tanga Region
84%
94%
72%
94%
33%
78%
82%
57%
32%
29%
71%
63%
Case study: QM in a Tanzanian Health Region
Scoring and Ranking
Case study: QM in a Tanzanian Health Region
 Answer the following questions:

Which are the different categories of HF?

Are their any areas with cannot be scored?

How to weight the remaining areas?

How weighting should be done within an
area?
Case study: QM in a Tanzanian Health Region








1. Leadership
2. Personal Management
3. Resource Management
4. Health Care Performance
5. Staff Satisfaction
6. Clients Satisfaction
7. Health Service Output
8. Health Service Outcome
 Max. Points
50
50
not scored
200
not scored
75
125
not scored
10%
10%
500
100%
40%
15%
25%
Case study: QM in a Tanzanian Health Region

Why these areas were not scored?

Financial Management:
HF are not comparable because
of different financial schemes

Staff Satisfaction:
In this first round the
questionnaires was anonymous

Health Service Outcome
Difficult to measure from a HF
perspective
** Only Health Centers could reach 500 points, for dispensaries without IPD and
laboratory the denominator is 363 points
This approach was not
accepted!
1. Supervision was not done according to
the planned schedule
2. Supervisions checklist have not been
filled in
3. If Supervision checklist have been
filled in, filling in was very often
incomplete