Transcript A MANAGEMENT PERSPECTIVE raghavan-gilbert/vw 1

A MANAGEMENT PERSPECTIVE
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QUALITY OF CARE & SERVICE
A MANAGEMENT PERSPECTIVE
 PROGRAMME JUSTIFICATION FOR
QUALITY
• Demographic approach & unmet needs
• Is quality the missing link?
• Target free approach
• Reward system and donors
• Wasted resources & opportunity costs
• Programme sustainability
• Stakeholders
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HEALTH & SOCIAL
JUSTIFICATION FOR QUALITY
 Direct relationship between high fertility




and maternal & child deaths
Access to and use of FP Services is
critical
Determinants of fertility known
Attitudinal & socio-psychological variables
Decision-making processes in human
reproductive behaviour
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MORAL & ETHICAL OBLICATIONS
 Ethical concerns
 Heightened Expectations
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Conceptual Framework of Family Planning Programme
Impact on Fertility in the Context of Supply and Demand
Other
Intermediate
Variables
Societal
Individual
Value and
Demand
for
Factors
Children
and
Development
Programs
Family
Planning
Supply Factors
FP Demand
 Spacing
 Limiting
Fertility
 Wanted
 Unwanted
Contraceptive
Practice
Service Outputs
 Access
 Quality
 Image/
Acceptability
Service
Utilization
Other Health
and Social
Improvements
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Source: Bertrand, et.al, 1992
Family Planning Supply Factors
External
Development
Assistance
Political and
Administrative
System

Political
Support

Resource
Allocations

Legal Code/
Regulations
Larger Societal
and Political
Governance
Factors
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FP
Organizational
Structure

Service
Infrastructure

Sectoral
Integration

Delivery
Strategies
Public
Private
Partnership
Operations

Management
and
Supervision

Training

Commodity
Acquisition/
Distribution

I-E-C
Research and

Evaluation
Conceptual Framework of
Family Planning Supply Factors
Source: Bertrand, et.a., The Evaluation Project 1992)
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Schematic presentation of links between quality
of family planning services and fertility (from Jain, 1989)
Quality
Services
of
 Choice
 Information to
users
 Provider
competence
 Client/Provider
relations
 Follow-up
 Appropriate
constellation
of services
Other
factors
including
demand
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Acceptance
Contraceptive
prevalence
Continuation
Fertility
Other
proximate
determinants
Known
effects
Hypothesized
effects
Jain, A., 1989
Source:
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KEY SYSTEMIC FEATURES OF A
FP PROGRAMME
 High interdependence
 Complex service delivery system
 Large information gaps between the
entities
 No consensus on output measure
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SPECIAL INTEREST GROUPS IN FP
PROGRAMME




Religious and cultural groups
Political mistrust
Human rights groups
Feminists groups
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WHY?

Reduces wastage of scarce resources

Provides a fuller understanding of the
problem

Prevents recurrence of a problem

Doing it Right the First Time (DRIFT)
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DEFINITION OF QUALITY
ISO 8402 (1986) ON QUALITY
VOCABULARY
The definition advanced by the ISO draws
attention to three key embedded concepts:
“Quality is the totality of features and
characteristics of a product or service that
bears on its ability to satisfy stated or
implied needs”. This definition of quality
encapsulates
its
complexity
and
multidimensionality.
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INDUSTRIAL QUALITY MODEL
Quality is conformance to specifications
that relate to customer satisfaction.
 Five quality dimensions relate to customer
satisfaction in industrial quality. Quality
measurement in industry necessarily reflects
these dimensions. They are:
• specification (preservice expectation)
• conformance (in relation to the expectation)
• reliability (over time)
• cost (value)
• delivery (timeliness)
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QUALITY IN HEALTH CARE






Self regulation
External Regulation
Medical Audits
Quality in FP
Bruce QOC Model
Other Models
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Quality of Care Framework – Bruce
ANTECEDENTS, ELEMENTS and OUTCOMES OF
FAMILY PLANNING SERVICES
Enabling systems for
Service Delivery
Resources available
Management structure
and capacity
Logistics
Impact
Elements of Quality of Care
1. Choice of Methods
Informed decision-making about
reproductive health options
2. Technical competence
Client health
3. Informing and counseling clients
Client knowledge
Training
4. Interpersonal relations
Client satisfaction
MIS
5. Mechanisms to encourage continuity
Contraceptive use
6. Appropriateness and acceptability
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Acceptance
Continuity
adapted from Bruce by the Subcommittee on Quality Indicators 1990
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SERVICE CHARACTERISTICS





Intangible Experience
Co-production
Simultaneity of production and
consumption
Client decides the continuation of the
relationship
Deficiencies, evident during transaction
or even later affects perception of
quality
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SERVICE CHARACTERISTICS

Quality service requires that critical
‘behind-the-scene’ activities meet quality
critieria before the first client-provider
interaction and service experience occurs.
This can happen only if organizational
processes are predetermined and quality
standards preset for the organization,
which providers can strive to reach in
service production and delivery
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A Conceptual Model of Service Quality
(Haywood - Farmer)
Professional
judgement
Physical
process
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People’s
behaviour
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The Service Quality Model – Gronroos
Expected
service
Perceived
service
Traditional marketing
activities (advertising,
field selling, public
relations, pricing); and
external influence by
traditions, ideology
and word-of-mouth
Image
Technical
quality
W hat?
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Functional
quality
How?
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From: Gronroos. 1990, A Service Quality Model and its Marketing Implications
DIFFICULTIES IN MEASUREMENT
OF SERVICE QUALITY




Client’s mental model
Courtesy bias
Empowerment of the customers
Diversity of Perspectives on Quality
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INTERPERSONAL PROCESS
 ‘The
virtues’ of the interpersonal process
of privacy, confidentiality, informed
choice, concern, empathy, honesty, tact
and sensitivity identified by Donabedian
(1988) be applied as programmatic
guidelines to assess and improve services in
the QOC model
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HEALTH CARE MANAGER’S
PERSPECTIVE

The production and maintenance of high
quality service


Non-physician manager
Clinician manager
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HEALTHCARE MANAGER’S
PERSPECTIVE

Managers tend to feel that technical
competence, efficiency, access and
effectiveness are the most important
dimensions of quality (Brown et al., 1993).
Less importance is given to the
interpersonal dimensions of service.
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HEALTH CARE PROVIDER’S
PERSPECTIVE

Management
customers

Commitment & motivation depends on the
organization enabling them
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enabling
the
internal
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HEALTH CARE PROVIDER’S
PERSEPCTIVE
 Providers
tend to focus on technical
competence, effectiveness and of course,
safety. This is for good clinical, ethical and
legal reasons. They need and expect effective
and efficient technical, administrative and
supportive services in providing high quality
service. Providers tend to underestimate the
importance of the role they play and the
attitudes they and other front-line staff have
in shaping the interpersonal experience of the
client and her perception of quality.
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DONOR/FUNDER PERSPECTIVE

Major donor interests in family planning,
until recently, have been driven mostly by
concerns related to reaching numerical
targets to measure impact, efficiency
and equity, and to a lesser extent by
considerations of ethics
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CLIENT PERSPECTIVE

Family planning clients and communities in
developing countries often focus on
interpersonal process, geographic and
financial accessibility, effectiveness of
method, continuity of provider and
physical amenities as the most important
dimensions of quality. May clients in
developing countries cannot adequately
assess technical competence because
power and knowledge asymmetries
between provider and client are too large
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SERVICE QUALITY MODEL





Quality of service is when client’s perception of
service received conforms to client’s expectation
of service
Tangibles: the physical facilities, equipment,
appearance of personnel
Reliability: the ability to perform the desired service
dependably, accurately and consistently
Responsiveness: the willingness to provide prompt
service and help customers
Assurance: employees’ knowledge, courtesy and
ability to convey trust and confidence
Empathy: the provision of caring, individualised
attention to customer
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TOTAL QUALITY MANAGEMENT
(TQM)
Systems model of a Quality Loop





Market research & specifications
Quality management system
Quality control system
Internal quality assurance systems
External quality assurance systems
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MANAGEMENT AND QUALITY
ASSURANCE

Finding & fixing problems in processes of
work



Identify performance gap
Cyclical continuous activity
Role of Leadership
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Selected Quality Assessment Tools
 Case Follow-up
 Client Satisfaction Studies
 Clinic Management System
 Competency testing
 Consumer/Client Intercept Studies
 Counselor Training Evaluation
 Demographic and Health Survey Oversample
 Focus Group Discussions
 Hypothetical Cases
 Management Information Systems
 Matrix (CEDPA)
 Matrix (Enterprise)
 Monitoring Voluntary Surgical Contraception
 Procedures
 Observation
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Selected Quality Assessment Tools
(cont’d)
 Operations Research
 Panel Studies
 Patient/Client Flow Analysis
 Peer Review
 Programme Quality Assessment Tool (PQAT)
 Quality Definition and Assessment
 Record Review
 Self-Assessment
 Simulated/Mystery Client Studies
 Situation Analysis
 Structured Interviews/Surveys
 Supervision Tool (CARE)
 SWOT Analysis
 Use and Discontinuation Studies
Source: Katz et,al.1993
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The Service Performance Gap
Factors affecting workforce
willingness & ability to perform
Management factors
affecting performance
Role Conflict
Unclear roles and responsibilities

Poor fit among elements of provider’s job

Lack of management
specifications for service
quality
Inadequate role support
Hiring practices,

Training programs

Support services

Neglecting the internal customer

Lack of management clarity and
commitment
Inadequate role environment
Organizational climate

Culture

Reward

Recognition

Lack of management concern
about workers morale
These create the service performance gap
These are responsible for the
service performance gap
Adapted from Berry et al., 1990
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ANALYSIS AND JUSTIFICATION OF PQAT CONTENT
Program quality
indicators in
PQAT
Competence
Criteria examined




Choice


Training
SOP use
Knowledge
Interpersonal
Range available
Method mix
Quality linked Issues
Activity targeted for
improvement
Imported technologies

Technology transfer and
integration




Infection control
Commodities storage





Safety



Options
Coercion
Paternalism
Invasive procedures
Method failure






Medical backup

Technical backup

Emergency protocols

Adequacy of
commodities

Written inventory

Unbroken supply

Adequacy of
expendables

Adequacy of
equipment


Written inventory

SOP application


Written inventory
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Safe practice


Case management
Practice
Communication
Supervision
Commodities acquisition
Provider training
Supervision
Training
Management support
Supervision
Organizational routines
Training
Organizational routines
Training
Organizational routines
Training
Organizational routines
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ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d
Program
quality
indicators in
PQAT
Physical
facilities
Guidelines &
Protocols
IEC
MIS
Supervision
Criteria examined
Quality linked Issues
Activity targeted
for improvement


Consumer
preferences

Client needs

Client satisfaction


Specify current
standard

Technical practice

Management
practice

Parallel activity

Communication



Appearance
Privacy

Ventilation

Water available

Toilet/WC

Signs and directions

Client flow

Clinical guidelines

Infection control
guidelines

Management SOP

Current literature

Hospital outreach

Community outreach

Teaching aids

Informational materials

Records and forms

Service statistics





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Project supervision
Clinic supervision
Supervisory tools
Supervisory workplan
Reliable client data

Reliable program
data

Close supportive
supervision

Structured
supervision
Upgrade
facilities

Management
training

Supervision
Management
support

Training

Supervision

Program policy

Organizational
routines
Program policy

Training

Supervision

Management
support

Training

Supervisory
systems
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ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d
Program
quality
indicators in
PQAT
Monitoring
Criteria examined


Client follow
up system

Accessibility






Quality linked Issues
Program performance
Program feedback

Defaulter tracing
Appointment system

Cost
Distance
Waiting time
Cultural barriers
Functional access

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

Activity targeted
for improvement
Intrinsic rewards
Motivation

Program continuity
Method continuity

Program policy changes

Program design
Program redesign
Program use

Program non-use

Method
discontinuation
Management, field, and trainer
linkages

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An Example of PQAT use from FHS Nigeria 1990-Clinic 7
Program Quality Indicator
Source of data
Assessment score
Criteria to be fulfilled
Standard to be met
Interview
Adequate
Observation
TECHNICAL
COMPETENCE (indicator)
1. Have the technical staff
X
received a minimum of two
weeks of pure FP training
before certification (Criteria)
(If less than 2 weeks then
mark not adequate)
(Standard)
2. Were clinical staff
X
required to do 10 IUD
insertions training prior to
certification
(Criteria)
(If less than 10 IUD
insertions under training
then mark not adequate)
(Standard)
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Explain score
‘The WHY?”
Recommendations
for improvement
Not
Adequate
IN
X
IN
Many sources of
training support
over the years
To build state
level training data
base to enable
planning for
prioritized training
needs
X
IN
The standard
differed with
source of
training support
For closer on-thejob training and
supervision by
state training
teams and
supervisors.
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An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)
Program Quality Indicator
Source of data
Assessment score
Criteria to be fulfilled
Standard to be met
Interview
Adequate
Observation
TECHNICAL
COMPETENCE (indicator)
3. Have technical staff had
refresher training within the
last 3 years?
(Criteria)
(If within 3 years then mark
adequate) (Standard)
4. Are infection control
guidelines & protocols (ICP)
followed? (Criteria)
(If absent, then mark not
adequate) (Standard)
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Explain score
‘The WHY?”
Recommendations
for improvement
Last training
received by
provider was
about 4 years ago.
Has depended on
national and state
training capacity
Breaches in ICP
observed. ICP
supplies in
shortage due to
central problems.
Errors in aseptic
techniques. SOPs
not provided
centrally
To be addressed as
a priority by the
current training
plans of the State
training teams.
Not
Adequate
IN
X
X
IN
X
IN
To improve the
central logistics
support systems of
ICP supplies
Closer OJT and
supervision in ICP
by clinic and state
level supervisors
FHS to expedite
the provision of
centrally
development
SOPs
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An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)
Program Quality Indicator
Source of data
Assessment score
Criteria to be fulfilled
Standard to be met
Interview
Adequate
Observation
TECHNICAL
COMPETENCE (indicator)
Recommendations
for improvement
Provider has
outdated
information
about oral pills
and client
selection. Lack
of FP knowledge
weakens
counseling,
causes
unnecessary
method
switching
Not developed
and provided
from HQ
To be addressed
through training
and on-the-job
supervision. To be
improved through
the provision of
SOPs for
reference.
Not
Adequate
IN
5. Are guidelines and
protocols used correctly in
case management? (Criteria)
(If correct then mark
adequate) (Standard)
X
IN
6. Are guidelines and
X
protocols used correctly in
on-the-job training and
supervisory training?
(Criteria)
(If used then mark adequate)
(Standard)
X
IN
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Explain score
‘The WHY?”
Central action is
urgently needed to
assist the trainers
and supervisors to
provide better
support.
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Findings from
Findings by
clinic
Competence
IEC
Management
MIS
Supervision
Monitoring
Client
follow up
Nigeria 1990
OYO
OYO
OYO
KADUNA
KADUNA KADUNA BENDEL
Clinic 1
Clinic 2
Clinic 3
Clinic 4
Clinic 5
Clinic 6
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
BENDEL
BENDEL
BENDEL
Clinic 7
Clinic 8
Clinic 9
Clinic 10
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
Commodities
Expendables
Equipment
Access
Physical
facilities
IN
IN
IN
IN
IN
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IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
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IN = Inadequate quality
Findings from the
SOLOMON
ISLANDS
Competence
Choice
Safety
Medical
Backup
Commodities
Consumables
Equipment
Physical
Facility
Access
Std. and
protocols
IEC
MIS
Supervision
Monitoring
Client
follow-up
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Clinic 1
Solomon Islands 1991
Clinic 2
IN
Clinic 3
Clinic 4
Clinic 5
Clinic 6
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
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IN
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IN
IN
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IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN = Inadequate quality
Blank box = Adequate quality
44
Findings from
VANUATU
Clinic 1
VANUATU 1991
Clinic 2
Clinic 3
Clinic 4
Clinic 5
Competence
IN
IN
IN
Choice
IN
IN
IN
Safety
IN
IN
Medical Backup
Commodities
IN
IN
IN
IN
IN
Consumables
IN
IN
IN
IN
IN
Equipment
IN
IN
IN
IN
IN
Physical Facility
IN
IN
Access
IN
IN
Std. &
protocols
IN
IN
IN
IN
IEC
IN
IN
IN
IN
IN
MIS
IN
IN
IN
IN
IN
Supervision
IN
IN
IN
IN
Monitoring
IN
IN
IN
IN
IN
IN
IN
Client follow-up
IN
IN
IN= Inadequate quality;
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Blank box = Adequate quality
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Findings from
FIJI
Competence
Choice
Safety
Medical
Backup
Commodities
Consumables
Equipment
Physical
Facility
Access
Std. &
protocols
IEC
MIS
Supervision
Monitoring
Client followup
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Cl
1
Cl 2
µ
ANC
IN
IN
Cl
3
FIJI
1991
Cl
4
Cl
5
Cl
6
Cl
7
Cl
8
Cl
9
IN
IN
IN
IN
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IN
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IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN = Inadequate quality
Blank box = Adequate quality
46
µ= Only motivation, no clinical services
“Would you tell me please, which way I ought to go
from here?”
“That depends a good deal on where you want to get
to,” said the Cat.
“I don’t much care where,” said Alice.
“Then it doesn’t matter which way you go,” said the
Cat.
“So long as I get somewhere,” Alice added as an
explanation.
“Oh, you’re sure to do that,” said the Cat,
“If you only walk long enough”.
Lewis Carroll, Alice in Wonderland
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Key References: Quality of Care
1. P.Raghavan-Gilbert, 1997 Service Quality Management in Family Planning: The
Program Quality Assessment model, a multipurpose management tool,
Doctoral Thesis, University of Exeter
2. Berry, L.L, Parasuraman, A, Zeithaml, V.A.1990 Quality Counts in Services
too. In: Clark G (ed), Managing Service Quality. An IFS Executive Briefing,
IFS Publications, UK
3. Bruce, J. 1989 Fundamental elements of quality of care: A Simple Framework,
The Population Council, Working Papers (1).
4. Network FHI, Vol. 14 No. 1 1993 Quality of Care - Ways to Improve Care
Focusing on Clients.
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