Barrier to implementing Quality improvement initiatives in low resource-limited setting

1. Barriers to Implementation of
Quality improvement Initiatives in
Resource Limited Set Up
Geetanjli Kalyan
Clinical Instructor
National Institute of Nursing Education,
PGIMER, Chandigarh

2. Quality Improvement
• Quality in health care is a direct correlation between the level of
improved health services and the desired health outcomes of
individuals and populations.
• Quality improvement (QI): consists of systematic and continuous
actions that lead to measurable improvement in health care
services and the health status of targeted patient groups.
Institute of Medicine (IOM)

3. “Crossing the Quality
Chasm”
• In 2001 IOM published a report “Crossing the Quality Chasm”
• This report was an urgent call for fundamental change to close
the quality gap
• It was mentioned that though providers have more research
findings and more technology available to them than ever before
still quality is in doubt.

4. Crossing the Quality Chasm: Six dimensions
of high-quality
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient centered
Special emphasis to
• Value (ratio of cost, quality care and equity)
• Access
• Prevention

5. High vs low income nations
• Where we don’t have resource constraints like in developed
economies/ high income nations all we can do is process
improvement
• Low resource setting there are many barriers and we need to find
out measures to overcome them

6. In resource limited setting
• Major Problem
• Access
• No means of carrying a labouring women living in an
oversea territory where mainland is separated by a river
(Sodzi Sodzi-Tettey, MD, MPH; IHI Senior Technical Director for
the Africa Region)
• True Indian Story: Dashrath Manjhi living in Gehlaur village,
near Gaya in Bihar, India who spent 22 years chiselling this
massive gap through a mountain out of love for his dead wife,
who died because the 34-mile route round to the nearest town
was too far to take her for urgent medical care The Mountain Man

7. Management related barrier
• Technical and structural,
• Poor maintenance of costly equipment
• Limited infrastructure
• Psychosocial
Ziegenfuss JT Jr. Qual Assur Util Rev. 1991
• Resource barriers: scarcity of important tools, and resources
• Poor patient referral system
• Poor performance of primary and secondary Health care system

8. Management related barrier …..contd…
• Frequent system breakdowns because of
• combination of resource constraints
• limitations of the health workforce
• poorly developed management systems.
• Weak accountability of staff
• Weak leadership structure

9. Staff related Barriers
• Low ratio of HCP : Patient
• Workload
• Poor patient care
• Weak adherence to treatment protocols
• Poor staff performance

10. Staff related Barriers
• Poor training
• Poor staff attitude
• No time to explain the patient
Josephine Nana Afrakoma Agyeman-Duah etal. BMC Health Serv Res. 2014
Advancing Quality Improvement Research

11. Barriers to QI as per Patients
• Lack some patient taking responsibility of their own health
• Poor amenities and services
• Weak adherence to treatment protocols
• Patients not involved in their own care
• Delayed treatment, long waiting time
• Wrong treatment
• Whom you know service
• Poor understanding of patients (illiterate)
Josephine Nana Afrakoma Agyeman-Duah etal. BMC Health Serv Res. 2014

12. Causes of failure of QI Initiatives
• Narrowly focused, outcome-oriented quality improvement
initiatives and sporadic accreditation visits fail to address
• Investments in health systems strengthening without continuous
quality improvement
• Only focusing on quality improvement in a resource-poor context
without engaging the broader health system for support

13. How to overcome
• Improving health care quality in low-income countries means
addressing problems such as:
• High adverse event rates
• Too few and poorly trained providers
• Limited diagnostic tools and equipment
• Delays in accessing medications and other treatments
• The need to effectively treat growing numbers of patients with non-
communicable diseases, such as cancer, heart disease, and diabetes

14. How to overcome
• Build a widely focused systems for ongoing, operational monitoring and
response
Mark Durand. International Journal for Quality in Health Care
• Five elements:
• (i) systems thinking
• (ii) stakeholders’ participation
• (iii) accountability
• (iv) evidence-based interventions
• (v) innovative evaluation
Bejoy Nambiar et al. Bull World Health Organ. 2017

15. Strategies for improving the quality of health
care for MCH in LMIC
• Overview of 27 Systematic review on the strategies for improving
the quality of health care for MCH in LMIC
Fernado A. etal. Perinatal Reasearch unit and Institute forclinical effectiveness and
health polcy. WHO- RPC Meeting
• Important is “Know-do-gap”: how to make the intervention of
known efficacy available LMIC
• Series of known effective intervention if implemented globally can
reduce maternal and child mortality.

16. Use of known effective intervention
• Fact (globally)
• Use known intervention to manage neonatal hypothermia are used in 20%
• Administration of antenatal steroid in no more than 5%
Jones G etal. Child Survival Study group. Lancet. 2003
• Already known interventions can reduce neonatal and child mortality by 40-
70%
Compell O, Ghraham W. Strategies for reducing maternal mortality:getting on what works. Lancet 2006

17. Findings
• Distribution of educational material: not effective alone
• Audit and feedback: small to moderate positive effect
• Reminder: low cost, small to moderate positive effect
• Educational meetings: small to moderate positive effect:
interactive workshops useful
• Educational outreach visits: effective but are costly

18. Findings ….. Contd…
• Local opinion leaders: small to moderate positive effect
• Patient mediated and mass media: less effective and costly. Effective
for educated who already advantaged
• Multifaceted interventions
• Tailored interventions to overcome barriers
• Organizational interventions
• Financial interventions

19. Improvement Is Begging to Happen
• we have to start where the problem is. He mentioned that we have
increased new-born services to over 80 whereas we had only 5 or
maybe 8 percent coverage.
Sodzi Sodzi-Tettey, MD, MPH; IHI Senior Technical Director for the Africa Region

20. Conclusion
• No magic bullet or simple solutions to improve quality
• We have to try and test as no single solution is applicable to all
problem
• Each setup has its own problem most appropriate tools has to be
selected out of broad categories of interventions
• Requires governance structure that assign responsibility for quality
improvement, priority setting, selection of designed interventions

21. Conclusion
• A multifaceted interventions integrated with interactive
workshops, distribution of simple printed material, and
application of manual reminders can be help.
• Conducted small quality improvement projects at own setup can
rewarding.

22. Refrences
• Agyeman-Duah JNA, Theurer A, Munthali C, Alide N, Neuhann F. Understanding the barriers to setting up a healthcare
quality improvement process in resource-limited settings: a situational analysis at the Medical Department of Kamuzu
Central Hospital in Lilongwe, Malawi. BMC Health Services Research. 2014;14:1. doi:10.1186/1472-6963-14-1.
• Nambiar B, Hargreaves DS, Morroni C, et al. Improving health-care quality in resource-poor settings. Bulletin of the World
Health Organization. 2017;95(1):76-78. doi:10.2471/BLT.16.170803.
• institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington (DC): National Academies Press (US); 2001.PubMed PMID: 25057539.
• Ziegenfuss JT Jr. Organizational barriers to quality improvement in medical and health care organizatio
• A. Mark Durand; Quality improvement and the hierarchy of needs in low resource settings: perspective of a district health
officer, International Journal for Quality in Health Care, Volume 22, Issue 1, 1 February 2010, Pages 70–
72, https://doi.org/10.1093/intqhc/mzp053ns. Qual Assur Util Rev. 1991 Winter;6(4):115-22. Review. PubMed PMID:
1824455.
• http://www.who.int/rpc/meetings/MCH_QI_strategies.pdf