Raghavan-gilbert/vw1 A MANAGEMENT PERSPECTIVE. raghavan-gilbert/vw2 QUALITY OF CARE & SERVICE A...

raghavan-gilbert/vw 1

A MANAGEMENT PERSPECTIVE


QUALITY OF CARE & SERVICEA 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


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


MORAL & ETHICAL OBLICATIONS

Ethical concerns

Heightened Expectations


Societal

andIndividual

Factors

Value andDemand

for

Children

FP Demand Spacing Limiting

OtherIntermediateVariables

ContraceptivePractice

Fertility Wanted Unwanted

Other Healthand Social

Improvements

ServiceUtilization

Service Outputs Access

QualityImage/Acceptability

DevelopmentPrograms

FamilyPlanningSupply Factors

Conceptual Framework of Family Planning ProgrammeImpact on Fertility in the Context of Supply and Demand

Source: Bertrand, et.al, 1992


Larger Societaland PoliticalGovernanceFactors

ExternalDevelopmentAssistance FP

OrganizationalStructure Service

Infrastructure SectoralIntegration DeliveryStrategies Public-PrivatePartnership

Political andAdministrativeSystem Political

Support ResourceAllocations Legal Code/Regulations

Operations ManagementandSupervision Training CommodityAcquisition/Distribution I-E-C Research andEvaluation

Conceptual Framework ofFamily Planning Supply Factors

Family Planning Supply Factors

Source: Bertrand, et.a., The Evaluation Project 1992)


Schematic presentation of links between quality

of f amily planning services and f ert ility (f rom J ain, 1989)

Hypothesizedeff ects

Q ualityofServices Choice I nformation to

users Provider

competence Client/ Provider

relations Follow- up Appropriate

constellationof services

Otherfactorsincluding demand

Acceptance

Continuation

Contraceptiveprevalence

Otherproximate

determinants

Fertility

Knowneff ects

Source:J ain, A. , 1989


KEY SYSTEMIC FEATURES OF A FP PROGRAMME

High interdependence Complex service delivery system Large information gaps between the

entities No consensus on output measure


SPECIAL INTEREST GROUPS IN FP PROGRAMME

Religious and cultural groups

Political mistrust

Human rights groups

Feminists groups


Family Planning Service Delivery and Stakeholders

PO LI CYMAKERS& DO N O RS

Providers

T echnicalT eam

S upportT eam

Communityawareness

S erviceProcess

Community

CLI EN T

I MPA CT

ProgramorFieldManagers

or ganisat ional cont ex t communit y cont ex t

PQ A Tactshere

S o u rce : R a g h a va n -G ilb ert, 1 99 7


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)


DEFINITION OF QUALITYISO 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.


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)


QUALITY IN HEALTH CARE

Self regulation

External Regulation

Medical Audits

Quality in FP

Bruce QOC Model

Other Models


Quality of Care Framework – Bruce

ANTECEDENTS, ELEMENTS and OUTCOMES OFFAMI LY PLANNI NG SERVI CES

Enabling systems forService Delivery

Elements of Quality of Care I mpact

Resources available

Management structureand capacity

Logistics

Training

MI S

1. Choice of Methods

2. Technical competence

3. I nforming and counseling clients

4. I nterpersonal relations

5. Mechanisms to encourage continuity

6. Appropriateness and acceptability

I nformed decision- making aboutreproductive health options

Client health

Client knowledge

Client satisfaction

Contraceptive use

Acceptance

Continuity

adapted f rom Bruce by the Subcommittee on Quality I ndicators 1990


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


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


Professionaljudgement

People’sbehaviour

Physicalprocess

A Conceptual Model of Service Quality(Haywood - Farmer)


The Service Quality Model – Gronroos

Expectedservice

Perceivedservice

Image

Technicalquality

Functionalquality

What? How?

Traditional marketingactivities (advertising,field selling, publicrelations, pricing); andexternal influence bytraditions, ideologyand word-of-mouth

From: Gronroos. 199 0, A S ervice 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


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


HEALTH CARE MANAGER’S PERSPECTIVE

The production and maintenance of

high quality service

Non-physician manager

Clinician manager


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.


HEALTH CARE PROVIDER’S PERSPECTIVE

Management enabling the internal customers

Commitment & motivation depends on the organization enabling them


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.


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


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


SERVICE QUALITY MODELQuality 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


Service- qualityimprovement

eff orts

UnitManagers

(FieldManagers)

Intermediateservice

providers(Support-

services team)

Customer-contact

personnel(providers)

Customers(FP clients)

Adapted from: Berry and Parasuraman, 1990, The Service Quality Puzzle


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


Program Q uality A ssessment Model

PO LI CY & donorinterests

Enabling S ystems

O RGA N I Z A T I O N A LRO UT I N ES

HUMA N RES O URCESstaffi ng & training

F. P. T ECH N O LO GY

& clinical procedures

FA CI LI T I ES

I . E. & C.

S ERVI CEELEMEN T S

CommunityI nterests

CLI EN T

I MPA CT

Resources &

Management

or ganisat ional cont ex t communit y cont ex t

Q uality- of - CareEvaluation

Q

U

A

L

I

T

Y

M

A

N

A

G

E

M

E

N

T

ProgramQ uality

A ssessment

S o u r c e : R a g h a v a n -G ilb e r t , A P H A 1 9 9 1


T he Discrepancy or Gap model f or Q uality A ssessment

3 Local Adaptation

2Decision toAssess(PQ AT )

1

Stakeholders

Perf ormanceStandards

(W hat should be)

Other

Actions

4T raining

5 Assessment (what is)

6 Follow- up action(to reach ‘should be’)

YES

FieldManagementFeedback

Policy & StrategyFeedback

PQAT

.S o u r c e : R a g h a v a n -G ilb e r t 9 7


MANAGEMENT AND QUALITY ASSURANCE

Finding & fixing problems in processes

of work

Identify performance gap

Cyclical continuous activity

Role of Leadership


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


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


The Service Performance GapFactors aff ecting workforcewillingness & ability to perform

Management factorsaff ecting performance

Role Conflict

Unclear roles and responsibilities

Poor fi t among elements of provider’s job

Lack of managementspecifications f or servicequality

I nadequate role support

Hiring practices,

Training programs

Support services

Neglecting the internal customer

Lack of management clarity andcommitment

I nadequate role environment

Organizational climate

Culture

Reward

Recognition

Lack of management concernabout workers morale

These create the service performance gap These are responsible for theservice performance gap

Adapted from Berry et al., 1990


Program qualityindicators inPQAT

Criteria examined Quality linked Issues Activity targeted forimprovement

Competence Training SOP use Knowledge Interpersonal

Imported technologies Technology transfer andintegration

Case management Practice Communication Supervision

Choice Range available Method mix

Options Coercion Paternalism

Commodities acquisition Provider training Supervision

Safety Infection control Commodities storage

Invasive procedures Method failure

Training Management support Supervision

Medical backup Technical backup Emergency protocols Organizational routines

Adequacy ofcommodities

Written inventory Unbroken supply Training Organizational routines

Adequacy ofexpendables

Written inventory SOP application Training Organizational routines

Adequacy ofequipment

Written inventory Safe practice Training Organizational routines

ANALYSIS AND JUSTIFICATION OF PQAT CONTENT


Programqualityindicators inPQAT

Criteria examined Quality linked Issues Activity targetedfor improvement

Physicalfacilities

Appearance Privacy Ventilation Water available Toilet/WC Signs and directions Client flow

Consumerpreferences Client needs Client satisfaction

Upgradefacilities Managementtraining Supervision

Guidelines &Protocols

Clinical guidelines Infection controlguidelines Management SOP Current literature

Specify currentstandard Technical practice Managementpractice

Managementsupport Training Supervision

IEC Hospital outreach Community outreach Teaching aids Informational materials

Parallel activity Communication

Program policy Organizationalroutines

MIS Records and forms Service statistics

Reliable client data Reliable programdata

Program policy Training Supervision

Supervision Project supervision Clinic supervision Supervisory tools Supervisory workplan

Close supportivesupervision Structuredsupervision

Managementsupport Training Supervisorysystems

ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d


Programquality

indicators inPQAT

Criteria examined Quality linked Issues Activity targetedfor improvement

Monitoring Program performance Program feedback

Intrinsic rewards Motivation

Management, field, and trainerlinkages

Client followup system

Defaulter tracing Appointment system

Program continuity Method continuity

Program policy changes

Accessibility Cost Distance Waiting time Cultural barriers Functional access

Program use Program non-use Methoddiscontinuation

Program design Program redesign

ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d


Program Quality Indicator Source of data Assessment score

Criteria to be fulfilledStandard to be met

Interview Obser-vation

Adequate NotAdequate

Explain score‘The WHY?”

Recommendationsfor improvement

TECHNICALCOMPETENCE (indicator)

IN

1. Have the technical staffreceived a minimum of twoweeks of pure FP trainingbefore certification (Criteria)(If less than 2 weeks thenmark not adequate)(Standard)

X X IN Many sources oftraining supportover the years

To build statelevel training database to enableplanning forprioritized trainingneeds

2. Were clinical staffrequired to do 10 IUDinsertions training prior tocertification(Criteria)(If less than 10 IUDinsertions under trainingthen mark not adequate)(Standard)

X X IN The standarddiffered withsource oftraining support

For closer on-the-job training andsupervision bystate trainingteams andsupervisors.

An Example of PQAT use from FHS Nigeria 1990-Clinic 7









IN

3. Have technical staff hadrefresher training within thelast 3 years?(Criteria)(If within 3 years then markadequate) (Standard)

X X IN Last trainingreceived byprovider wasabout 4 years ago.Has depended onnational and statetraining capacity

To be addressed asa priority by thecurrent trainingplans of the Statetraining teams.

4. Are infection controlguidelines & protocols (ICP)followed? (Criteria)(If absent, then mark notadequate) (Standard)

X IN Breaches in ICPobserved. ICPsupplies inshortage due tocentral problems.Errors in aseptictechniques. SOPsnot providedcentrally

To improve thecentral logisticssupport systems ofICP suppliesCloser OJT andsupervision in ICPby clinic and statelevel supervisorsFHS to expeditethe provision ofcentrallydevelopmentSOPs

An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)









IN

5. Are guidelines andprotocols used correctly incase management? (Criteria)(If correct then markadequate) (Standard)

X IN Provider hasoutdatedinformationabout oral pillsand clientselection. Lackof FP knowledgeweakenscounseling,causesunnecessarymethodswitching

To be addressedthrough trainingand on-the-jobsupervision. To beimproved throughthe provision ofSOPs forreference.

6. Are guidelines andprotocols used correctly inon-the-job training andsupervisory training?(Criteria)(If used then mark adequate)(Standard)

X X IN Not developedand providedfrom HQ

Central action isurgently needed toassist the trainersand supervisors toprovide bettersupport.

An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)


Findings from Nigeria 1990

Findings byclinic

OYO OYO OYO KADUNA KADUNA KADUNA BENDEL BENDEL BENDEL BENDEL

Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8 Clinic 9 Clinic 10

Competence IN IN IN IN IN IN IN IN IN IN

I EC IN IN IN IN IN IN IN IN IN IN

ManagementIN IN

MIS IN IN IN IN Supervision IN IN IN IN

Monitoring IN IN IN IN Clientfollow up

IN IN IN IN IN IN IN IN

CommoditiesIN IN IN IN

ExpendablesIN IN IN IN IN IN IN IN IN IN

Equipment IN IN IN IN IN IN IN

Access IN IN IN

Physicalfacilities

IN IN IN

IN = Inadequate quality


Findings from the Solomon I slands 1991

SOLOMONI SLANDS

Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6

Competence I N I N I N I NChoice I N I NSafety I N I N I N I NMedicalBackup

I N I N

Commodities I N I N I NConsumables I N I N I N I N

Equipment I N I N I NPhysicalFacility

I N I N I N I N

Access I N I N I N I N I NStd. andprotocols

I N I N I N I N I N I N

I EC I N I N I N I N I NMIS I N I N I N I N I N I NSupervision I N I N I N I N I NMonitoring I N I N I N I N I N I NClientfollow- up

I N I N I N I N I N I N

IN = Inadequate qualityBlank box = Adequate quality


Findings from VANUATU 1991

VANUATU Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5

Competence I N I N I N

Choice I N I N I N

Safety I N I N

Medical Backup

Commodities I N I N I N I N I N

Consumables I N I N I N I N I N

Equipment I N I N I N I N I N

Physical Facility I N I N

Access I N I N

Std. &protocols

I N I N I N I N

I EC I N I N I N I N I N

MI S I N I N I N I N I N

Supervision I N I N I N I N

Monitoring I N I N I N I N

Client followup I N I N I N I N I N

IN= Inadequate quality; Blank box = Adequate quality


Findings from FI J I 1991

FI J I Cl1

Cl 2µ

ANC

Cl3

Cl4

Cl5

Cl6

Cl7

Cl8

Cl9

Competence I N I N I N I N I N I N I N I N

ChoiceSafetyMedicalBackupCommodities I N

ConsumablesEquipmentPhysicalFacility

I N I N I N I N I N

Access I N I N

Std. &protocols

I N I N I N I N I N I N I N I N I N

I EC I N I N I N I N I N I N I N I N I N

MI S I N I N I N I N I N I N

Supervision I N I N I N I N I N I N

Monitoring I N I N I N I N

Client follow-up

I N I N I N I N I N I N I N

IN = Inadequate qualityBlank box = Adequate quality

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


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.

Key References: Quality of Care

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