PHA 038 (Intro to Health Systems) SAS #4 PDF

Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________...

Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ Lesson title: Quality of Healthcare Services based on the Materials: pen, SAS different resources of the Healthcare Systems Lesson Objectives: References: At the end of the module, you should be able to: Romualdez, et.al (2011). The 1. Analyze the quality of healthcare service provided. Philippine Health System Review. Health Systems in Transition, vol.1 2. Differentiate the services of a healthcare system. Nisce, et. Al (1995). Community Health Nursing Services in the Philippine Department of Health. 8th edition. Manila. Population Center Foundation. 1990. Community Organizing: A Manual on the HRDP Experience. Manila Miller and Keane. (1987). Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. Philadelphia Dizon, E. (1979). Community Health Nursing in the Philippines. Manila Lipsitz,L. (2012) Understanding Health Care as a Complex System. The Journal of the American Medical Association. Productivity Tip: Try the Pomodoro Technique! Set your timer to 25 minutes and work during this time period. After this period, take a 5-minute break. Repeat ☺ A. LESSON PREVIEW/REVIEW 1  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ Introduction (2 mins) Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes. The care provided should be effective, evidence-based and neither underused nor overused. The concept of clinical effectiveness tends to shift attention away from inputs such as drugs and equipment and towards the process of care. Clinical processes are directly attributable to the behavior of health care providers and their measurement can provide a critical starting point in the development of methods to improve care received by patients. Although health outcomes can be informative, they are only likely to be a crude measure of quality because of the inherent unpredictably in patients` responses to health care. Activity 1: What I Know Chart, part 1 (3 mins) Instruction: in this chart reflect on what you know now. Do not worry if you are sure or not sure of your answers. This activity simply serves to get you started on thinking about our topic. Answer only the first column, “What I know”. Leave the third column “What I Learned” blank at this time. What I Know Questions: What I Learned (Activity 3) 1.What is clinical quality of care? 2. How perceptions and understanding of quality of care influence health systems? Activity 2: (50mins) MAIN LESSON Policies to improve population health have often focused exclusively on the expansion of access to basic health services, to the neglect of quality of care. Efforts to increase the demand for priority interventions have implicitly assumed that the care available is of sufficient quality or that, with the expansion of coverage, quality will naturally improve. However, such assumptions may be incorrect. 2  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ - There is growing recognition that people may be acting in a perfectly rational way when they avoid using health services of poor quality and that poor quality of care can be a barrier to universal health coverage independent of access. - The aim of many strategies to improve health-care quality has been to ensure that essential inputs – e.g. technology, operational facilities, pharmaceutical supplies and trained health workers – are in place. Many such strategies have focused on the supply side and been designed to support the provision of services according to clinical guidelines. - The acknowledgement that quality improvement approaches should be applied within patient-centred models of care is relatively recent. In this session, we seek to unpack complexities around quality of care and identify strategies for improving the measurement of such quality. - An understanding of these issues could inform pragmatic strategies for the analysis and measurement of quality of care. We draw on research conducted in a variety of low- and middle-income countries and identify areas of inherent complexity that require further in-depth research. In doing so, we reflect on what is meant by quality of care and how perceptions and understanding of quality-of-care influence health systems and effect the measurement of quality. - It has been identified and structured our discussion around six conceptual and measurement challenges. (1) First is the recognition that, even though they may not reflect actual quality, perceptions of the quality of care are an important driver of care utilization. (2) Second, a patient’s experience of quality must be conceptualized as occurring over time. (3) Third, responsiveness to the patient is a key attribute of quality. (4) Fourth, so-called upstream factors – e.g. management at facility and higher levels – are likely to be important for quality. (5) Fifth, quality can be considered as a social construct co-produced by different actors. (6) Finally, there are substantial measurement challenges that require the adaptation and improvement of current approaches. - The classic framework on quality of care developed by Donabedian makes the distinction between structure, process and outcomes. More recently, the Institute of Medicine in the United States of America (USA) has unpacked the concept further and suggested that efforts to improve care quality should be focused around six aims: effectiveness, efficiency, equity, patient-centeredness, safety, and timeliness. - WHO does not seek to propose a new framework for understanding quality. Rather, it highlights some key issues that deserve more consideration in debates about enhancing the accessibility and quality of care. Building on our experiences of doing empirical research in low- and middle-income countries, we present several insights that are complementary to existing, comprehensive frameworks of quality of care and may be absent from current debates. Clinical quality - Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes. The care provided should be effective, evidence-based and neither underused nor overused. - While relatively easy to measure, the availability of inputs cannot generally be used in isolation to determine if a patient’s health is likely to improve because of the care received. - Clinical processes are directly attributable to the behavior of health-care providers and their measurement can provide a critical starting point in the development of methods to improve care received by patients. Although health outcomes can be informative, they are only likely to be a crude measure of quality because of the inherent unpredictability in patients’ responses to health care. Assessment Assessment of the clinical quality of care poses several conceptual and practical challenges. It requires a strong evidence base that can act as a benchmark against which to evaluate interventions. 3  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ In high-income countries, treatments received can be compared with the treatments recommended in national guidelines. In many low- and middle-income countries, however, such guidelines are either not available or poorly enforced. Even when such guidelines are present, the evaluation of what constitutes the overprovision of care is not clear-cut and requires careful judgement. Although harmful care should be distinguished from unnecessary care, such categorization can be difficult in practice. Care for a single patient may be provided over the course of numerous interactions by a large team of health professionals. In such circumstances, measurement of the quality of care often focuses on a small number of distinct interventions with proven efficacy. There are several well-known practical challenges to the assessment of the clinical quality of care. For example, it may not be possible to observe the interactions between patients and their physicians and, when they are possible, such observations can generate bias through the Hawthorne effect, i.e. health-care providers change their behavior when observed. In low- and middle-income countries, medical records are often poorly maintained and may not reflect actual practice. The use of so-called undercover or standardized patients in the assessment of clinical care may raise ethical concerns, is generally limited to non-invasive conditions and is not a practical solution to the routine measurement of quality. Despite these challenges, an influential literature on the clinical quality of care in low- and middle-income countries is emerging. Perceived quality - Attempts to improve the quality of care have often been underpinned by a biomedical understanding of quality – i.e. the conceptualization of a gold standard of quality guided by clinical guidelines – that can lead to a narrow focus. Provider practices tend to vary despite the existence of accountability procedures and guidelines. - Interventions may not be implemented as intended or easily accommodated within established models of care. Clinical quality is important for patient outcomes but perceptions of the quality of care – which may not correlate with actual quality – are likely to be the key drivers of utilization. - Patients may also find it difficult to evaluate the quality of care because they lack their physician’s medical expertise and training. - In South Africa, a key motivating factor in patients’ travel to access health services – including travel across borders – was found to be the patients’ perceptions of the quality of health services.20 Patients may sometimes believe an ineffective and unsafe treatment to be good, even when they have access to effective and safe treatments. - In Malaysia, for example, many people with hypertension seek potentially ineffective and unsafe treatments from traditional practitioners. Perceptions of the quality of care are based on a mix of individual experience, processed information and rumor. - In Uganda, perceptions of the quality of the care that was locally available were found to have persuaded many women to seek maternal care away from their local area – apparently regardless of the availability of transportation and the distances involved. - In Bangladesh, despite a nationwide expansion in the network of health facilities, facility-based deliveries remained rare and most women still attempted to give birth at home or, in the case of complications, at distant periurban health centers that the women believed to offer care of higher quality than that available at the community facilities closest to their homes. Patients’ trust in services has been shown to be an important element of perceived quality. 4  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ Perceptions on the quality of care - Perceptions of the quality of care may relate entirely to non-clinical factors. For example, criminalized or marginalized populations – e.g. some ethnic or sexual minorities – may judge the quality of care only according to the extent that the care environment is non-discriminatory or supportive. - In Zambia, many patients considered public-sector clinics supported by one nongovernmental organization to be better than other public-sector facilities that apparently provided the same standardized package of care. - The effect of perceived quality is not limited to delivery models. Among remote rural populations in Armenia, there was disappointingly low participation in community-based health-insurance schemes because the quality of the care provided by the schemes was perceived to be low. - Despite the often-high out-of-pocket costs, most people in the communities covered by the schemes preferred to use district-based clinics and hospitals – where they believed the quality of care to be higher than in the facilities covered by the schemes. - Although quality is a construct largely based on individual subjective perceptions, such perceptions are shaped by collective and traditional beliefs and peer influences. While improving or, at least, maintaining the actual quality of the care they provide, health systems need to address – and ultimately close – the gap between perceived and actual quality. Quality as a social construct ◊ Assessment of quality of care in low- and middle-income countries is frequently conducted at the individual level by using various tools – e.g. clinical observations, exit and in-depth interviews, extraction of medical records, role-playing vignettes and standardized patients, designed to assess both patients’ experiences and technical quality. However, social networks influence perceptions relating to both health services and illness. Therefore, for a comprehensive investigation of the development of the general publics and patients’ perceptions of the quality of care, we need to examine community and family values. ◊ In many situations, patients may have responses to a health provider’s actions and, similarly, providers may adapt their responses to patients to suit social norms. ◊ For example, a patient may be recommended a clinical investigation and they may either agree to be investigated – e.g. if the proposed investigation is offered by a provider trusted by the patient’s social network – or they may exit the system and seek care elsewhere, e.g. from a more trusted traditional practitioner. Such responses may be considered as a social relationship that can happen in formal care settings, or elsewhere. ◊ Perception of quality can also be shaped by power relationships in society. In a study in the Russian Federation, the women most likely to undergo pregnancy-related procedures were found to be the relatively young and poorly educated. Although such women were relatively poor and therefore found it particularly hard to pay for their care, they appeared to be given little choice – possibly because of their relatively low social status and inability to negotiate care that was commensurate to their needs. ◊ Similar discrepancies between what health professionals felt would improve the quality of care for non-compliant patients and those patients’ preferences and wishes were observed in a study of tuberculosis cases in India. In that study, the number of treatment choices offered was found to be positively correlated with social status. 5  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ Measurement challenges ◊ Considering the above discussion, there is a case for taking a broader perspective when measuring quality of care. Although this has been recognized by the World Health Organization’s monitoring framework for universal health coverage – which considers effectiveness of treatment, patient safety, people-centeredness and the level of integration of health services as key dimensions – the focus of recent assessments of the quality of care has been on indicators of health-service coverage. ◊ It is suggested that for a comprehensive and detailed assessment of the quality of health services, both clinical and perceived quality of care need to be evaluated and then compared. Alongside technical measures of quality, attention should be given to manifestations of quality – e.g. acceptability, cultural appropriateness and responsiveness. ◊ Strategies to improve clinical quality only have the potential to increase demand for care if the general public’s perceptions of the quality of the care available also improve. ◊ Any evaluation of the overall quality of care needs to consider a patient’s experience of quality as a cumulative process. ◊ Changing patterns of illness and increasing numbers of treatment options mean that an increasing amount of health care involves a sequence of interlinked contacts – with a range of health professionals at different levels of the health system – over a lengthy period. ◊ A patient’s perceptions may vary widely as treatment follows diagnosis and follow-up follows treatment, with each stage potentially affecting the patient’s subsequent choices. By measuring clinical and perceived quality at each key step in this continuum of care, it should be possible to generate a better, more nuanced understanding of how patients interact with health systems. ◊ A growing body of work focusing on measures of patients’ perceptions now exists. To understand these perceptions more holistically, qualitative methods need to become an integral part of quality assessments. In such assessments, theory-driven hierarchical models can be useful in generating propositions to guide empirical research or help deepen interpretation. ◊ Mid-range programmed theories and open-box evaluations have also been useful in examining why and how particular health programs work. Although the measurement of indicators that are rapidly observed by patients seeking care – e.g. staff attitudes and waiting times – can be useful, it is important to delve deeper and study how upstream factors, such as management practices, matter – e.g. by influencing staff morale. Use of carefully selected proxies for quality of care and comparison of findings generated through different methods may help to inform pragmatic intervention strategies. ◊ Finally, assessment of individual perceptions of the quality of care and examination of how such perceptions are rooted in community, family and societal expectations, norms and values may offer a promising way forward. ◊ Perceived quality may correlate closely with the expectations and social status of the users themselves, the circumstances in which the users obtain care and/or the levels of community cohesion and resources that enable collective action. Although the inclusion of contextual variables and appropriate units of observation for studying community and social group-level characteristics may be methodologically challenging, it is important for understanding individual choices and perceptions. Conclusion: 6  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ Recognition of the multifaceted nature of the quality of care is critical for scaling up priority health interventions. If uptake of health services is to be increased, we require not only better technical quality but also better acceptability and patient-centeredness – across the continuum of care. Perceptions of quality are shaped by interconnected community, health-system and individual factors. Moreover, quality of care cannot be understood fully without some appreciation of the social norms, relationships and values and trust within the communities and societies where care is provided. Activity 3: What I Learned, part 2 (3 mins) Instruction: To review your answers and what was learned from the session today. Please go back to activity 1 and answer the “what I learned” column of the chart. Notice and reflect on any changes in your answers. Activity 4: Check for Understanding (60 mins) Instruction: Now it`s time for you to figure this one out on your own! Take time to read, understand, answer and rationalize the following questions. This will be recorded as your quiz. Superimpositions or erasures in your answer/ratio is NOT allowed. Correct answers will be provided during our discussion forum. GOOD LUCK! ☺ Multiple Choice: 1. Policies to improve population health have often focused exclusively on the expansion of access to basic health services, to the neglect of quantity of care. Efforts to decrease the demand for priority interventions have implicitly assumed that the care available is of sufficient quality or that, with the expansion of coverage, quality will naturally improve. a. The first statement is true c. Both statements are true b. The first statement is false d. Both statements are false ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 7  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ 2. The aim of many strategies to improve health-care quality has been to ensure that essential inputs, examples are the following, except? a. Technology c. Operational facilities b. Pharmaceutical medication d. Trained health workers ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 3. The acknowledgement that quality improvement approaches should be applied within _______ models of care is relatively recent a. Community centered c. Patient centered b. Physician centered d. All of the above ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 4. Which of the following is false? a. Recognition that, even though they may not reflect actual quality, perceptions of the quality of care are an important driver of care utilization. b. A patient’s experience of quality must be conceptualized as occurring over time. c. Responsiveness to the patient is a key attribute of quantity. d. So-called upstream factors – e.g. management at facility and higher levels – are likely to be important for quality ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 5. WHO does not seek to propose a new framework for understanding quality. Rather, it highlights some key issues that deserve more consideration in debates about enhancing the accessibility and quality of ________ a. Care c. Life b. Health d. Population ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 6. What relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes? a. The bulk of the population size c. Clinical quality of care b. Quality of medicines d. All are correct ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 8  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ 7. In such circumstances, measurement of the quality of care often focuses on a small number of distinct interventions with proven ______. a. Quality c. Structure b. Efficacy d. B and C are correct ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 8. Similar discrepancies between what health professionals felt would improve the quality of care for non-compliant patients and those patients’ preferences and wishes were observed in a study of tuberculosis cases in India. In that study, the number of treatment choices offered was found to be positively correlated with social status. a. The first statement is true c. Both statements are true b. The first statement is false d. Both statements are false ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 9. Strategies to improve clinical quality only have the potential to increase demand for care if? a. The general public’s perceptions of the quality of the care available also improve. b. Most of the population will improve on medication adherence c. The public will start using generics instead of the innovator brand d. All the above ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 10. A patient’s perceptions may vary widely as treatment follows diagnosis and follow-up follows treatment, with each stage potentially affecting the patient’s subsequent choices. By measuring clinical and perceived quality at each key step in this continuum of care, it should be possible to generate a better, more nuanced understanding of how patients interact with health systems. a. The second statement is false c. Both statements are true b. The second statement is true d. Both statements are false ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 11. A growing body of work focusing on measures of patients’ perceptions now exists. To understand these perceptions more holistically, qualitative methods need to become an integral part of __________ a. Quantity assessments c. Quality assessments b. Quarterly assessments d. Patient assessments ANSWER: ________ 9  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 12. What have also been useful in examining why and how particular health programs work. a. Clinical assessments c. Mid-range program theories b. Open-box evaluation d. B and C are correct ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 13. What is critical for scaling up priority health interventions? a. Medication expenses c. Recognition of the multifaceted nature of the quality of care b. Salary expenses for the physicians d. A and C are correct ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 14. Quality of care cannot be understood fully without some ____________ within the communities and societies where care is provided. a. Appreciation of the social norms c. Relationships b. Values and trust d. All are correct ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ 15. What can also be shaped by power relationships in society a. Perception of quality c. Quality of the knowledge of a given population b. Perception of power d. All of the above ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ C. LESSON WRAP-UP Activity 5: Thinking about Learning (4 mins) A. Work Tracker: 10  Course Code: PHA 038 (Intro to Health Systems) SAS #4 Name: ____________________________________________________ Class number: _____ Section: ____________ Schedule: _____________________________ Date: ____________ You are done with this session! Let’s track your progress. Shade the session number you just completed. INTRO TO HEALTH SYSTEMS P1 P2 P3 1 2 3 4 5 6 7 8 9 10 B. Think About your Learning: Tell me about your thoughts on today`s topic. What surprised you about the lesson today? Please explain why. 11